ENT OF HEALTH & HUMAN SERVICES • US

RAPED

MT

A 

CENTERS FOR DISEASE CONTROL 

AND PREVENTION 

Tobacco Use Among
 

U.S. Racial/Ethnic
 

Minority Groups
 

African Americans 

American Indians and Alaska Natives 

Asian Americans and Pacific Islanders 

Hispanics 

A Report of the 

Surgeon General 

1998 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Chronic Disease Prevention and Health Promotion 

Office on Smoking and Health 
Suggested Citation 

U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic 

Minority Groups—African Americans, American Indians and Alaska Natives, Asian Americans 

and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Atlanta, Georgia: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1998. 

For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C., 20402, S/N 017-001-00527-4. 

Use of trade names is for identification only and does not constitute endorsement by the 

U.S. Department of Health and Human Services. 

Foreword 

The United States of America is a rich blend of cultures. This diversity 

demands close attention from the agencies and individuals responsible for protecting the public’s health. For too long in tobacco control, attention to diversity 

has been less consistent than is necessary for planning and developing effective 

health programs. As a result, we sometimes lack sufficient information on which 

to base tobacco control interventions. With this report, we begin to address such 

problems and point the way to filling these gaps in knowledge. 

Tobacco use causes devastating disease and premature death in every 

population in the United States. For four major U.S. racial/ethnic minority groups— 

African Americans, American Indians and Alaska Natives, Asian Americans and 

Pacific Islanders, and Hispanics—patterns of tobacco use, adverse health effects, 

and the effectiveness of interventions need to be understood in terms of tobacco’s 

cultural and socioeconomic effects on the members of these groups. This report 

describes the complex factors that play a part in the growing epidemic of diseases 

caused by tobacco use in these four groups. 

Since 1964 when the first Surgeon General’s report on smoking and health 

was released, this report is the first to focus exclusively on tobacco use among 

members of these four racial/ethnic groups. Together these groups constitute about 

25 percent of the U.S. population, and that proportion is growing rapidly. Public 

health programs must effectively address the health needs of this significant proportion of people. Such action is of paramount importance to reducing tobacco 

use in the United States and meeting national health objectives for the year 2000. 

We hope that this report will provide the basis for renewing our commitment to 

develop more effective tobacco control programs and policies for people of every 

racial and ethnic background. In addition, the report can be used by parents and 

communities as a tool to develop their own solutions. With continued diligence, 

we shall strive to reach and exceed whenever possible our stated health goals by 

the year 2000 and reduce the enormous health burden caused by tobacco products. 

Claire V. Broome, M.D. 

Acting Director 

Centers for Disease Control and Prevention 

and 

Acting Administrator 

Agency for Toxic Substances and Disease Registry 

i 

Preface 

from the Surgeon General, 

U.S. Department of Health and Human Services 

Effective strategies are needed to reduce tobacco use among members of U.S. 

racial/ethnic groups and thus diminish their burden of tobacco-related diseases 

and deaths. Cigarette smoking is the leading cause of preventable disease and 

death in the United States. There is enormous potential to reduce heart disease, 

cancer, stroke, and respiratory disease among members of racial and ethnic groups, 

who make up the most rapidly growing segment of the U.S. population. 

This Surgeon General’s report is the first to address the diverse tobacco 

control needs of the four major U.S. racial/ethnic minority groups—African 

Americans, American Indians and Alaska Natives, Asian Americans and Pacific 

Islanders, and Hispanics. This report is also the only single, comprehensive source 

of data on each group’s patterns of tobacco use, physical effects related to tobacco 

smoking and chewing, and societal and psychosocial factors associated with 

tobacco use. 

The findings detailed in this report indicate that if tobacco use is not reduced 

among members of these four racial/ethnic groups, they will experience increasing morbidity and mortality from tobacco use. The toll is currently highest for 

African American adults. Findings also suggest that some close, long-term relationships between tobacco companies and various racial/ethnic communities could 

hamper U.S. efforts to lower rates of tobacco use by the year 2000. Also notable is 

the support that members of racial/ethnic groups have shown for legislative 

efforts to control tobacco use, sales, advertising, and promotion. 

As this report goes to press, discouraging news comes from a report 

published by the Centers for Disease Control and Prevention on the Youth Risk 

Behavior Survey about tobacco use among African American and Hispanic high 

school students. Past-month smoking increased among African American students 

by 80 percent and among Hispanic students by 34 percent from 1991 through 1997. 

The consistent decline once seen among young African Americans has sharply 

reversed in recent years. Past-month smoking prevalence increased from 13 percent to 23 percent among African Americans and from 25 percent to 34 percent 

among Hispanics. 

Although cancer remains common in Americans of all racial and ethnic groups, 

the pattern of increasing lung cancer deaths in the 1970s and 1980s among African 

American, Hispanic, and some American Indian and Alaska Native subgroups 

has been halted or reversed for some groups from 1990 through 1995. Some encouraging news from Cancer Incidence and Mortality, 1973–1995: A Report Card for 

the U.S. was just published by the American Cancer Society, the National Cancer 

Institute, and the Centers for Disease Control and Prevention. The report described 

lung cancer trend data from 1990 through 1995 for African Americans, Asian Americans and Pacific Islanders, and Hispanics. Lung cancer death rates declined 

significantly for African American men and for Hispanic men and women from 

iii 
1990 through 1995; death rates did not change significantly for African American 

women or for Asian American and Pacific Islander men or women. Although lung 

cancer trends may continue to decline among some racial/ethnic groups for several more years, recent increases in smoking prevalence among adolescent African 

Americans and Hispanics and among Asian American and Pacific Islander adolescent males, coupled with the lack of decline among American Indian and Alaska 

Native adults, do not bode well for long-term trends in lung cancer. 

One purpose of this report is to guide researchers in their future efforts to 

garner more information needed to develop effective prevention and control programs. Several significant research questions need to be addressed. For example, 

why are African American youths smoking cigarettes in lower proportions than 

youths in other racial/ethnic groups? How does acculturation affect patterns of 

tobacco use among immigrants to the United States? What are the differential 

effects of gender on tobacco use among members of certain racial/ethnic groups? 

What racial- and ethnic-specific protective factors and risk factors will promote 

the development of culturally appropriate interventions to prevent and control 

tobacco use? And to what extent are culturally specific tobacco control programs 

necessary to curb tobacco use among racial/ethnic populations? While researchers are redirecting their focus, federal, state, and private tobacco control partners 

need to address program issues, such as how to develop and evaluate culturally 

appropriate prevention and cessation interventions. 

This report includes examples of numerous racial- and ethnic-specific 

tobacco control programs used in communities across the country. These and other 

racial/ethnic group-specific programs must be disseminated to all areas of the 

country, where program planners can develop their own strategies, taking into 

consideration the cultural attitudes, norms, expectations, and values of the 

targeted cultural groups. 

In each of these endeavors, we will succeed only if we are sensitive to our 

cultural differences and similarities. I challenge federal and state agencies as well 

as researchers and practitioners in the social, behavioral, public health, clinical, 

and biomedical sciences to join me in the pursuit of effective strategies to prevent 

and control tobacco use among racial/ethnic groups. By meeting this challenge, 

we will progress toward achieving the nation’s year 2000 tobacco-related health 

objectives and will help to prevent the unnecessary disability, disease, and deaths 

that result from tobacco use. 

David Satcher, M.D., Ph.D. 

Surgeon General 

and 

Assistant Secretary for Health 

iv 
Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Acknowledgments 

This report was prepared by the U.S. Department of 

Health and Human Services under the general direction of the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention 

and Health Promotion, Office on Smoking and Health. 

Claire V. Broome, M.D., Acting Director, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

James S. Marks, M.D., M.P.H., Director, National 

Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Virginia S. Bales, M.P.H., Deputy Director, National 

Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Michael P. Eriksen, Sc.D., Director, Office on Smoking 

and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

The editors of the report were 

Gerardo Marín, Ph.D., Senior Scientific Editor, Professor, Department of Psychology, University of San Francisco, San Francisco, California. 

Gayle Lloyd, M.A., Managing Editor, Office on Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Valerie R. Johnson, Senior Editor, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Anne M. Pritchett, Technical Editor, Cygnus Corporation, Rockville, Maryland. 

Contributing authors were 

Neal L. Benowitz, M.D., Professor and Chief, Division 

of Clinical Pharmacology, Departments of Medicine, 

Pharmacy, and Psychiatry, School of Medicine, University of California, San Francisco, California. 

Alan Blum, M.D., Associate Professor, Baylor College 

of Medicine, Houston, Texas. 

Ronald L. Braithwaite, Ph.D., Associate Professor, Division of Behavioral Sciences and Health Education, 

Emory University School of Public Health, Atlanta, 

Georgia. 

Felipe G. Castro, M.S.W., Ph.D., Director, Hispanic 

Research Center, and Associate Professor, Department 

of Psychology, Arizona State University, Tempe, 

Arizona. 

Moon S. Chen, Jr., Ph.D., M.P.H., Professor, Department of Preventive Medicine, Ohio State University, 

Columbus, Ohio. 

David B. Coultas, M.D., Associate Professor of Medicine, School of Medicine, University of New Mexico, 

Albuquerque, New Mexico. 

Luis G. Escobedo, M.D., M.P.H., Medical Epidemiologist, Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Dorothy L. Faulkner, Ph.D., M.P.H., Epidemiologist, 

Office on Smoking and Health, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Larri L. Fredericks, Ph.D., M.P.H., Associate Scientist, 

American Indian Cancer Control Project, Medical Research Institute, Berkeley, California. 

Gary A. Giovino, Ph.D., Chief, Epidemiology Branch, 

Office on Smoking and Health, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Sandra W. Headen, Ph.D., Assistant Professor, Department of Health Behavior and Health Education, School 

of Public Health, University of North Carolina, Chapel 

Hill, North Carolina. 

Felicia Schanche Hodge, Dr.P.H., Principal Investigator and Director, Center for American Indian Research 

and Education, Berkeley, California. 

Nancy J. Kaufman, R.N., M.S., Vice President, Robert 

Wood Johnson Foundation, Princeton, New Jersey. 

v 
Surgeon General's Report 

Juliette S. Kendrick, M.D., Medical Epidemiologist, 

Division of Reproductive Health, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Gary King, Ph.D., Assistant Professor and Coordinator, Urban Health Research Program, School of Medicine, University of Connecticut Health Center, 

Farmington, Connecticut. 

Beverly S. Kingsley, Ph.D., M.P.H., Epidemiologist, 

Office on Smoking and Health, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Rod Lew, M.P.H., Health Education Director, Asian 

Health Services, Oakland, California. 

Ann M. Malarcher, Ph.D., Epidemiologist, Office on 

Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Robert K. Merritt, M.A., Health Scientist, Division of 

Reproductive Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Michael D. Newcomb, Ph.D., Professor, Department 

of Psychology, University of California, Los Angeles, 

California. 

John P. Peddicord, M.S., Computer Scientist, Office on 

Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Richard Pollay, Ph.D., Professor of Marketing, and 

Curator, History of Advertising Archives, University 

of British Columbia, Vancouver, British Columbia, 

Canada. 

Amelie G. Ramirez, Dr.P.H., Associate Professor, Department of Family Practice, University of Texas, and 

Director, South Texas Health Research Center, San 

Antonio, Texas. 

Patricia A. Richter, Ph.D., M.P.H., Toxicologist, Office 

on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Robert G. Robinson, Dr.P.H., Associate Director for 

Program Development, Office on Smoking and Health, 

National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Richard B. Rothenberg, M.D., M.P.H., Professor, Department of Family and Preventive Medicine, Emory 

University School of Medicine, Atlanta, Georgia. 

Jonathan M. Samet, M.D., Chairman, Department of 

Epidemiology, School of Hygiene and Public Health, 

The Johns Hopkins University, Baltimore, Maryland. 

Michael W. Schooley, M.P.H., Epidemiologist, Office 

on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Dana Shelton, M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Michael B. Siegel, M.D., M.P.H., Assistant Professor, 

Boston University School of Public Health, Boston, 

Massachusetts. 

Charyn D. Sutton, President, The Onyx Group, Bala 

Cynwyd, Pennsylvania. 

Scott L. Tomar, D.M.D., Dr.P.H., Assistant Professor, 

Department of Dental Public Health and Hygiene, 

School of Dentistry, University of California, San Francisco, California. 

Bao-Ping Zhu, M.S., M.B.B.S., Ph.D., Visiting Scientist, 

Office on Smoking and Health, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Reviewers were 

Jasjit S. Ahluwalia, M.D., M.P.H., M.S., Assistant Professor of Medicine, Emory University School of Medicine, Atlanta, Georgia. 

David G. Altman, Ph.D., Associate Professor, Department of Public Health Sciences, Bowman Gray School 

of Medicine, Wake Forest University, Winston-Salem, 

North Carolina. 

vi 
Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Glen Bennett, M.P.H., Coordinator, Office of Prevention, Education, and Control, National Heart, Lung, 

and Blood Institute, National Institutes of Health, 

Bethesda, Maryland. 

Gilbert J. Botvin, Ph.D., Director, Institute for Prevention Research, Department of Public Health, Cornell 

University Medical College, New York, New York. 

L. Jackson Brown, Director, Epidemiology and Oral 

Disease Prevention Program, National Institute of 

Dental Research, National Institutes of Health, 

Bethesda, Maryland. 

Linda Burhansstipanov, Dr.P.H., Director, Native 

American Cancer Research Program, American Medical Center Cancer Research Center, Denver, Colorado. 

David Burns, M.D., Professor of Medicine, University 

of California at San Diego Medical Center, San Diego, 

California. 

W. Michael Byrd, M.D., M.P.H., Visiting Research Fellow, Department of Health Policy and Management, 

Harvard School of Public Health, Boston, Massachusetts. 

Portia S. Choi, M.D., M.P.H., District Health Officer, Dr. 

Ruth Temple Health Center, Los Angeles, California. 

Nathaniel Cobb, M.D., Director, Cancer Prevention and 

Control Program, Indian Health Service Headquarters 

West, Albuquerque, New Mexico. 

Janet L. Collins, Ph.D., Director, Division of Nutrition 

and Physical Activity, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Robert J. Collins, D.M.D., Chief Dental Officer, U.S. 

Public Health Service, Rockville, Maryland. 

Linda S. Crossett, R.D.H., Research Scientist, Division 

of Adolescent and School Health, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

K. Michael Cummings, Ph.D., Director, Smoking Control Program, Roswell Park Cancer Institute, New York 

State Department of Health, Buffalo, New York. 

Dorynne J. Czechowicz, M.D., Associate Director for 

Medical and Professional Affairs, Division of Clinical 

Research, National Institute on Drug Abuse, National 

Institutes of Health, Rockville, Maryland. 

Ronald M. Davis, M.D., Director, Center for Health 

Promotion and Disease Prevention, Henry Ford Health 

System, Detroit, Michigan. 

Richard A. Daynard, Ph.D., J.D., Chairman, Tobacco 

Products Liability Project, Northeastern University 

School of Law, Boston, Massachusetts. 

Jane L. Delgado, Ph.D., President and Chief Executive 

Officer, National Coalition of Hispanic Health and 

Human Services Organization, Washington, D.C. 

John Elder, Ph.D., M.P.H., Professor, Graduate School 

of Public Health, San Diego State University, San Diego, California. 

Harmon Eyre, M.D., Deputy Executive Vice President 

for Medical Affairs and Research, American Cancer 

Society, Atlanta, Georgia. 

Michael C. Fiore, M.D., M.P.H., Director, Center for 

Tobacco Research and Intervention, University of Wisconsin Medical School, Madison, Wisconsin. 

Adele M. Franks, M.D., Assistant Director for Science, 

National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Harold P. Freeman, M.D., Director of Surgery, Harlem 

Hospital Center, New York, New York. 

Thomas J. Glynn, Ph.D., Chief, Prevention Control 

Extramural Research Branch, National Cancer Institute, National Institutes of Health, Rockville, Maryland. 

Michael G. Goldstein, M.D., Associate Professor of 

Psychiatry and Human Behavior, Brown University 

School of Medicine, Providence, Rhode Island. 

Robert A. Hahn, Ph.D., M.P.H., Epidemiologist, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia. 

Betty Lee Hawks, M.A., Special Assistant to the Director, Office of Minority Health, U.S. Department of 

Health and Human Services, Rockville, Maryland. 

Clark W. Heath, Jr., M.D., Vice President for Epidemiology and Surveillance Research, American Cancer 

Society, Atlanta, Georgia. 

Jack E. Henningfield, Ph.D., Vice President, Pinney 

Associates, Bethesda, Maryland. 

vii 
Surgeon General's Report 

John H. Holbrook, M.D., Director of Internal Medicine, 

University of Utah Hospital, Salt Lake City, Utah. 

Thomas Houston, M.D., Director, Department of Preventive Medicine and Public Health, American Medical Association, Chicago, Illinois. 

Rudolph S. Jackson, Dr.P.H., Professor, Department of 

Health Education, North Carolina Central University, 

Durham, North Carolina. 

Elaine M. Johnson, Ph.D., Director, Center for 

Substance Abuse Prevention, Substance Abuse and 

Mental Health Services Administration, Rockville, 

Maryland. 

Nora L. Keenan, Ph.D., Epidemiologist, Office of Surveillance and Analysis, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Monina Klevens, D.D.S., M.P.H., Medical Officer, Division of HIV/AIDS, National Center for Infectious 

Diseases, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Norman A. Krasnegor, Ph.D., Chief, Human Learning 

and Behavior Branch, Center for Research for Mothers and Children, National Institute of Child Health 

and Human Development, National Institutes of 

Health, Bethesda, Maryland. 

Leonard E. Lawrence, M.D., President, National Medical Association, University of Texas Health Sciences 

Center at San Antonio, San Antonio, Texas. 

Edward Lichtenstein, Ph.D., Research Scientist, Oregon 

Research Institute, Eugene, Oregon. 

Douglas S. Lloyd, M.D., M.P.H., Associate Administrator for Public Health Practice, Health Resources and 

Services Administration, U.S. Department of Health 

and Human Services, Rockville, Maryland. 

Judith Mackay, M.B.E., J.P., F.R.C.P., Director, Asian 

Consultancy on Tobacco Control, Kowloon, Hong 

Kong. 

Audrey F. Manley, M.D., M.P.H., President, Spelman 

College, Atlanta, Georgia. 

Alfred McAlister, Ph.D., Associate Professor and Associate Director, Center for Health Promotion Research 

and Development, The University of Texas at Austin, 

Austin, Texas. 

J. Michael McGinnis, M.D., Scholar-in-Residence, 

National Academy of Sciences, Washington, D.C. 

Bertha Mo, Ph.D., M.P.H., Senior Program Officer, International Development Research Centre, Ottawa, 

Ontario, Canada. 

C. Tracy Orleans, Ph.D., Senior Program Officer, 

The Robert Wood Johnson Foundation, Princeton, New 

Jersey. 

Terry F. Pechacek, Ph.D., Visiting Scientist, Office on 

Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Cheryl L. Perry, Ph.D., Professor, Division of Epidemiology, School of Public Health, University of 

Minnesota, Minneapolis, Minnesota. 

John P. Pierce, Ph.D., Sam M. Walton Professor for 

Cancer Research, Department of Family and Preventive Medicine, University of California, San Diego, 

California. 

Donald H. Reece, Tobacco Control Coordinator, Indian 

Health Service, Albuquerque, New Mexico. 

Patrick Remington, M.D., M.P.H., Chief Medical Officer, 

Wisconsin Division of Health, Madison, Wisconsin. 

Irene Reveles-Chase, M.P.H., Health Education Consultant, Tobacco Control Section, California Department of Public Health, Sacramento, California. 

Nancy A. Rigotti, M.D., Director, Quit Smoking Service, General Internal Medicine Unit, Massachusetts 

General Hospital, Boston, Massachusetts. 

Donald J. Sharp, M.D., Medical Epidemiologist, Office on Smoking and Health, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Donald R. Shopland, Coordinator, Smoking and Tobacco Control Program, National Cancer Institute, 

National Institutes of Health, Bethesda, Maryland. 

Beverly R. Singer, M.A., Research Staff Associate, 

School of Social Work, Columbia University, New York, 

New York. 

viii 
Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Jesse L. Steinfeld, M.D., Surgeon General, U.S. Public 

Health Service, 1969–1973, San Diego, California. 

Jonathan R. Sugarman, M.D., M.P.H., Medical Epidemiologist, Portland Area Indian Health Service, Seattle, 

Washington. 

Michael J. Thun, M.D., Director, Analytic Epidemiology, American Cancer Society, Atlanta, Georgia. 

Michael H. Trujillo, M.D., M.P.H., Director, Indian 

Health Service, Rockville, Maryland. 

Kenneth E. Warner, Ph.D., Richard D. Remington Collegiate Professor of Public Health, Department of 

Health Management and Policy, School of Public 

Health, University of Michigan, Ann Arbor, Michigan. 

Raymond Weston, Ph.D., Postdoctoral Fellow, Memorial Sloan-Kettering Cancer Center, Division of Psychiatry, New York, New York. 

Judith Wilkenfeld, J.D., Assistant Director, Division of 

Advertising Practices, Federal Trade Commission, 

Washington, D.C. 

Jerome Williams, Ph.D., Professor of Marketing, Pennsylvania State University, University Park, Pennsylvania. 

Ernst L. Wynder, M.D., President, American Health 

Foundation, New York, New York. 

Other contributors were 

Marco Andujar, Telecommunications Specialist, Office 

on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Ruth Atchison, Proofreader, Cygnus Corporation, 

Rockville, Maryland. 

Cheryl Baldwin, Graphic Artist/Desktop Publishing 

Specialist, High 5 Design, Gaithersburg, Maryland. 

Mary Bedford, Proofreader, Cygnus Corporation, 

Rockville, Maryland. 

Christine V. Bellantoni, Graduate Student, University of 

Connecticut Health Center, Farmington, Connecticut. 

Maureen Berg, Desktop Publishing Specialist, Market 

Experts, Silver Spring, Maryland. 

Marissa Bernstein, Indexer, Cygnus Corporation, 

Rockville, Maryland. 

Nowell D. Berreth, Writer-Editor, Office on Smoking 

and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Joyce Buchanan, Administrative Assistant, Institute for 

Social Research, Survey Research Center, University 

of Michigan, Ann Arbor, Michigan. 

Janine E. Bullard, Proofreader, Cygnus Corporation, 

Rockville, Maryland. 

Ralph S. Carabello, Ph.D., Epidemiologist, Office on 

Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Jeffrey H. Chrismon, Systems Analyst, TRW Inc., 

Atlanta, Georgia. 

Paulette Clark McGee, Proofreader, Cygnus Corporation, Rockville, Maryland. 

Coreen A. Colovos, Copy Editor, Cygnus Corporation, 

Rockville, Maryland. 

David F. Coole, M.S., Statistical Programmer, TRW Inc., 

Atlanta, Georgia. 

Karen M. Deasy, Associate Director, Office on Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Washington, D.C. 

Susan R. Derrick, Program Analyst, Office on Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Ellen C. Dreyer, R.N., M.S., Project Director, Cygnus 

Corporation, Rockville, Maryland. 

Rita Elliott, M.A., Editorial Consultant, University of 

New Mexico, School of Medicine, Albuquerque, New 

Mexico. 

Raymond J. Gamba, M.S., Graduate Student, The 

Claremont Graduate School, Claremont, California. 

Maritta Perry Grau, M.A., Copy Editor, The Write 

Touch: Editorial Services, Frederick, Maryland. 

ix 
Surgeon General's Report 

Sarah Gregory, Acting Managing Editor, Office on 

Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Lillian E. Hatch, M.S.L.S., Information Specialist, Cygnus Corporation, Rockville, Maryland. 

Elizabeth L. Hess, Copy Editor, Cygnus Corporation, 

Rockville, Maryland. 

Thomya Hogan, Proofreader, Cygnus Corporation, 

Rockville, Maryland. 

Reta N. Horton, M.A., Secretary, Office on Smoking 

and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Frederick L. Hull, Ph.D., Writer-Editor, Technical Information and Editorial Services Branch, National 

Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Mescal J. Knighton, Writer-Editor, National Center for 

Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Anh Lé, Project Coordinator, Vietnamese Community 

Health Promotion Project, University of California, San 

Francisco, California. 

Yun Chen W. Lin, M.P.H., Technical Information Specialist, TRW Inc., Atlanta, Georgia. 

William T. Marx, M.L.I.S., Technical Information Specialist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. 

Maribet McCarty, R.N., M.P.H., Technical Information 

Specialist, The Orkand Corporation, Atlanta, Georgia. 

Margie McDonald, Word Processing Specialist, Cygnus Corporation, Rockville, Maryland. 

Linda A. McLaughlin, Word Processing Specialist, 

Cygnus Corporation, Rockville, Maryland. 

Jennifer A. Michaels, M.L.S., Technical Information 

Specialist, Office on Smoking and Health, National 

Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Barbara A. Mills, Secretary, Office on Smoking and 

Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. 

Paul D. Mowery, M.S., Senior Research Scientist, 

Battelle Memorial Institute, Atlanta, Georgia. 

Leslie A. Norman, Public Affairs Specialist, Office on 

Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Ward C. Nyholm, Desktop Publishing Specialist, 

Cygnus Corporation, Rockville, Maryland. 

Patrick O’Malley, Ph.D., Research Scientist, Institute 

for Social Research, Survey Research Center, University of Michigan, Ann Arbor, Michigan. 

Anniette Ponce de León, Student, University of San 

Francisco, San Francisco, California. 

Felicia A. Powell, M.S., Statistical Programmer, TRW 

Inc., Atlanta, Georgia. 

Christopher Rigaux, Project Director, Cygnus Corporation, Rockville, Maryland. 

Patricia L. Schwartz, Graphic Artist/Desktop Publishing Specialist, Cygnus Corporation, Rockville, Maryland. 

Matthew B. Spangler, Proofreader, Cygnus Corporation, Rockville, Maryland. 

Catherine T. Timmerman, Chief Operating Officer, 

Cygnus Corporation, Rockville, Maryland. 

Peggy E. Williams, M.S., Proofreader, Marietta, Georgia. 

Eve J. Wilson, Ph.D., Project Manager, Cygnus Corporation, Rockville, Maryland. 

Beatrice K. Wolman, M.S., Project Manager, Cygnus 

Corporation, Rockville, Maryland. 

x 


Chapter 1
 

Introduction and Summary of Conclusions
 

Introduction 5
 

Major Conclusions 6
 

Preparation of This Report 7
 

Terms Related to Race and Ethnicity 7
 

Terms Related to Tobacco Use 8
 

Demographic Characteristics of the Four Racial/Ethnic Minority Groups 8
 

Effects of Racial/Ethnic Background on Health 11
 

Chapter Conclusions 12
 

Chapter 2. Patterns of Tobacco Use Among Four Racial/Ethnic Minority Groups 12
 

Chapter 3. Health Consequences of Tobacco Use Among Four Racial/Ethnic
 

Minority Groups 

Chapter 4. Factors That Influence Tobacco Use Among Four Racial/Ethnic
 

Minority Groups 

Chapter 5. Tobacco Control and Education Efforts Among Members
 

of Four Racial/Ethnic Minority Groups 

12
 

13
 

14
 

References 15
 
 
Introduction and Summary 5 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Introduction 

This Surgeon General’s report on tobacco use 

summarizes current information on risk factors and 

patterns related to tobacco use among members of four 

major racial and ethnic minority groups in the United 

States: African Americans, American Indians and 

Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. In addition, this report presents 

information on national and regional efforts to curtail 

consumption of tobacco products among members of 

these four groups. Previous Surgeon General’s reports 

on smoking and health have briefly summarized findings related to one or more of the racial/ethnic groups 

covered in this report, but this is the first Surgeon 

General’s report to concentrate specifically on the four 

major racial/ethnic groups in the United States. 

Several factors prompted the development of this 

report. First, the information in this report has never 

before been compiled in one source. Consequently, 

policymakers, community leaders, researchers, and 

public health workers have had difficulty determining the extent of the problem, identifying gaps in information regarding tobacco use among members of 

the four groups, or being aware of existing tobacco control programs that have demonstrated effectiveness. 

Thus, incorporating such information into the design 

and implementation of culturally appropriate services 

has been difficult. 

Second, the four racial/ethnic groups currently 

constitute about one-fourth of the population of this 

country, and the Bureau of the Census projects that by 

2050 the non-Hispanic white population in the United 

States will total only 53 percent (Day 1996). Preventing health problems related to tobacco use among the 

individuals in racial and ethnic groups will be integral to achieving U.S. public health objectives, such as 

those proposed in Healthy People 2000: National Health 

Promotion and Disease Prevention Objectives (U.S. Department of Health and Human Services [USDHHS] 1991, 

1995; National Center for Health Statistics [NCHS] 

1994). 

This report contributes essential knowledge that 

must be incorporated into efforts to accomplish the 

Healthy People 2000 objectives, particularly these six 

goals: 

•	 Objective 3.1. Reduce coronary heart disease deaths 

to no more than 100 per 100,000 people. (Ageadjusted baseline: 135 deaths per 100,000 people 

in 1987.) Among African Americans, reduce the 

number from 168 to 115 deaths per 100,000 people 

between 1987 and the year 2000 (Objective 3.1a). 

•	 Objective 3.2. Slow the rise in lung cancer deaths 

to achieve a rate of no more than 42 per 100,000 

people. (Age-adjusted baseline: 38.5 deaths per 

100,000 people in 1987.) Among African American males, slow the rise from 86.1 to 91 deaths per 

100,000 people between 1990 and the year 2000 

(Objective 3.2b). 

•	 Objective 3.4. Reduce the prevalence of cigarette 

smoking to no more than 15 percent among people 

aged 18 years and older. (Baseline: 29 percent in 

1987 [31 percent for men and 27 percent for 

women].) Particular year 2000 objectives include 

lowering the prevalence of smoking to 18 percent 

among African Americans (Objective 3.4d), 15 percent among Hispanics (Objective 3.4e), and 20 percent among American Indians and Alaska Natives 

(Objective 3.4f) and Southeast Asian men (Objective 3.4g). 

•	 Objective 3.5. Reduce the initiation of cigarette 

smoking by children and youths so that no more 

than 15 percent have become regular cigarette 

smokers by the age of 20 years. (Baseline: 30 percent of youths had become regular cigarette smokers by the ages of 20–24 years in 1987.) 

•	 Objective 3.9. Reduce the prevalence of smokeless 

tobacco use among males aged 12–24 years to no 

more than 4 percent. (Baseline: 6.6 percent among 

males aged 12–17 years in 1988; 8.9 percent among 

males aged 18–24 years in 1987.) A specific objective is to lower the prevalence of smokeless tobacco 

use among American Indian and Alaska Native 

young adults to 10 percent by the year 2000 (Objective 3.9a). 

•	 Objective 3.18. Reduce stroke deaths to no more 

than 20 per 100,000 people. (Age-adjusted baseline: 

30.4 deaths per 100,000 people in 1987.) Among 

African Americans, reduce the number from 52.5 

to 27.0 deaths per 100,000 people between 1987 and 

the year 2000 (Objective 3.18a). 
6 Chapter 1 

Surgeon General’s Report 

This report of the Surgeon General also responds 

to the need to thoroughly analyze the smoking-related 

health status of racial/ethnic groups and to determine 

if there is a differential risk for tobacco addiction (Chen 

1993). High risk might derive from personal characteristics but also from social factors, such as migratory 

patterns, acculturation, and the tobacco industry’s historical involvement in the racial/ethnic communities 

and targeted advertising and promotion of tobacco 

products (see Chapter 4). 

In addition, this report is needed to document 

how patterns of health, disease, and illness among 

people in the various racial/ethnic minority groups 

differ from patterns in the rest of the U.S. population. 

These differences reflect the groups’ exposure to tobacco products, as well as the heterogeneity of the 

groups’ lifestyles, cultural beliefs and practices, genetic 

backgrounds, and environmental exposures. This report illustrates how patterns of tobacco use differ 

among and within the four racial/ethnic groups 

(Chapter 2). It compares the groups in terms of the 

incidence and the prevalence of death rates for 

diseases commonly associated with tobacco use and 

presents data from case-control and cohort studies 

whenever possible (Chapter 3). 

The health status of members of racial and ethnic groups in this country has also been the focus of 

previous federal reports, such as the Health Status of 

Minorities and Low-Income Groups (Health Resources 

and Services Administration [HRSA] 1985), the Report 

of the Secretary’s Task Force on Black and Minority Health 

(USDHHS 1985), and Chronic Disease in Minority Populations (Centers for Disease Control and Prevention 

[CDC] 1994). This Surgeon General’s report supports 

initiatives such as the Hispanic Health and Nutrition 

Examination Survey in the early 1980s; the Surgeon 

General’s National Hispanic/Latino Health Initiative 

(Novello and Soto-Torres 1993); special funding initiatives from federal agencies such as the CDC, the 

National Cancer Institute, the National Institute on 

Alcohol Abuse and Alcoholism, the National Institute 

on Drug Abuse, the National Heart, Lung, and Blood 

Institute (1994), and the National Institute of Mental 

Health (National Institutes of Health 1993); 

the Department of Health and Human Services’s 

1996 Hispanic Agenda for Action: Improving Services to 

Hispanic Americans, and the 1998 President’s Race Initiative, which includes special funding initiatives for 

the CDC, the Indian Health Service, and the Health 

Resources and Services Administration. 

Major Conclusions 

1.	 Cigarette smoking is a major cause of disease and 

death in each of the four population groups studied in this report. African Americans currently 

bear the greatest health burden. Differences in the 

magnitude of disease risk are directly related to 

differences in patterns of smoking. 

2.	 Tobacco use varies within and among racial/ 

ethnic minority groups; among adults, American 

Indians and Alaska Natives have the highest 

prevalence of tobacco use, and African American 

and Southeast Asian men also have a high prevalence of smoking. Asian American and Hispanic 

women have the lowest prevalence. 

3.	 Among adolescents, cigarette smoking prevalence 

increased in the 1990s among African Americans 

and Hispanics after several years of substantial decline among adolescents of all four racial/ethnic 

minority groups. This increase is particularly striking among African American youths, who had the 

greatest decline of the four groups during the 1970s 

and 1980s. 

4.	 No single factor determines patterns of tobacco use 

among racial/ethnic minority groups; these patterns are the result of complex interactions of multiple factors, such as socioeconomic status, cultural 

characteristics, acculturation, stress, biological elements, targeted advertising, price of tobacco 

products, and varying capacities of communities 

to mount effective tobacco control initiatives. 

5.	 Rigorous surveillance and prevention research are 

needed on the changing cultural, psychosocial, and 

environmental factors that influence tobacco use 

to improve our understanding of racial/ethnic 

smoking patterns and identify strategic tobacco 

control opportunities. The capacity of tobacco 

control efforts to keep pace with patterns of tobacco use and cessation depends on timely recognition of emerging prevalence and cessation 

patterns and the resulting development of appropriate community-based programs to address the 

factors involved. 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Preparation of This Report 

This report of the Surgeon General was prepared 

by the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, U.S. 

Department of Health and Human Services, as part of 

the Department’s mandate, under Public Laws 91–222 

and 99–252, to report to the U.S. Congress current information about the health effects of tobacco use. 

The report was produced with the assistance of 

experts in the behavioral, epidemiological, medical, 

and public health fields. Initial background papers 

were produced by more than 25 scientists who were 

selected because of their expertise and familiarity with 

the topics covered in this report. Their various contributions were summarized into five major chapters that 

were reviewed by 28 peer reviewers. The entire manuscript was then sent to 43 scientists and experts, who 

reviewed it for its scientific integrity. Subsequently, 

the report was reviewed by various institutes and 

agencies within the Department of Health and Human 

Services. 

Terms Related to Race and Ethnicity 

Race and ethnicity are classifications currently 

used for various purposes, such as tracking morbidity 

and mortality statistics, defining group characteristics 

(as is done in many studies and by most federal and 

state agencies, including the U.S. Bureau of the Census), and exploring the health characteristics of individuals and groups. Most extant data consider four 

racial groups in the United States (African American 

or black, American Indian and Alaska Native, Asian 

American and Pacific Islander, and white) as well as 

two ethnic categories (Hispanic and non-Hispanic). 

Specific choices have been made in selecting the 

labels used to identify individuals who share a given 

race, tradition, culture, or ethnicity. These labels differ somewhat from those published in the Race and 

Ethnic Standards for Federal Statistics and Administrative Reporting, more commonly known as Directive 15 (U.S. Department of Commerce 1978). This directive presents rules for classifying persons into four 

racial groups (American Indian or Alaskan Native, 

Asian or Pacific Islander, black, and white) and two 

ethnic categories (Hispanic origin and not of Hispanic 

origin). The labels in this report were chosen to reflect 

current preferred use by many members of each group 

and researchers as well as to more clearly identify 

members of a given group. Nevertheless, because of 

differences in the way in which ethnicity has been ascertained in the various studies, some overlap and 

misclassification may exist, particularly with regard 

to Hispanic origin (for example, Hispanics of African 

background may be classified as African Americans, 

or Hispanics may be classified as non-Hispanic 

whites). In addition, the terms used in this report do 

not always precisely depict the racial/ethnic group 

studied (for instance, this report consistently uses the 

term American Indian and Alaska Native, even when describing studies of Native Americans—a category that 

in some cases excludes Alaska Natives). Moreover, 

the terms used here do not reflect the fact that some 

studies were conducted in the 48 contiguous states and 

may exclude a substantial number of Alaska Natives 

and Native Hawaiians. Throughout this report, the 

following labels and definitions are used, with the referents basically agreeing with those of Directive 15: 

•	 African American. Individuals who trace their ancestry of origin to Sub-Saharan Africa. 

•	 American Indian and Alaska Native. Persons who 

have origins in any of the original peoples of North 

America and who maintain that cultural identification through self-identification, tribal affiliation, 

or community recognition. 

•	 Asian American and Pacific Islander. Individuals 

who trace their background to the Far East, Southeast Asia, the Indian subcontinent, or the Pacific 

Islands. 

•	 Hispanic. Persons who trace their background to 

one of the Spanish-speaking countries in the 

Americas or to other Spanish cultures or origins. 

•	 White. Persons who have origins in any of the 

original peoples of Europe, North Africa, or the 

Middle East. Throughout most of this report, 

white refers to non-Hispanic whites. 

Finally, this report avoids using such labels as 

people of color, special populations, multicultural populations, or diverse populations because some people consider them inaccurate, improper, or pejorative. Without question, not everyone will agree with the terms 

used in this report because no universally accepted 

labels exist. These terms will continue to evolve with 

time. 

Introduction and Summary 7 
8 Chapter 1 

Surgeon General’s Report 

Terms Related to Tobacco Use 

Throughout this report, prevalence of smoking cessation is used to describe the proportion of persons who 

had ever smoked and who were former smokers at 

the time of survey (this term is used instead of quit 

ratio or quit rate). Definitions related to smoking 

status—ever smokers, never smokers, current smokers, and former smokers—are presented later in this 

report (see Chapter 2). 

Demographic Characteristics of the Four 

Racial/Ethnic Minority Groups 

In the 1990 U.S. Census, the four racial and ethnic groups that are the focus of this report accounted 

for 24 percent of the population, or more than 60 million people (Table 1). African Americans were the largest group, followed by Hispanics, Asian Americans 

and Pacific Islanders, and American Indians and 

Alaska Natives. Although these groups constitute a 

minority of the total population, their overall growth 

of 32 percent between 1980 and 1990 far exceeds the 4­

percent increase among whites (Table 1). Asian Americans and Pacific Islanders had the largest growth 

during that period, followed by Hispanics, American 

Indians and Alaska Natives, and African Americans. 

Because of this rapid growth, racial and ethnic populations tend to be younger than the white majority. 

Demographic characteristics vary significantly 

when the four racial and ethnic groups are compared 

with whites, according to 1990 census data (Table 2; 

within-group variability is masked because all subgroups that make up a given racial or ethnic group are 

considered together) (U.S. Bureau of the Census 1993c). 

The median ages of Hispanics (25.6 years), as well as 

American Indians and Alaska Natives (26.9 years), are 

lower than those of the other racial/ethnic group members. Hispanics have the lowest proportion of high 

school graduates (49.8 percent) of all groups and the 

highest proportion of people who speak a language 

other than English (77.8 percent). Asian Americans 

and Pacific Islanders (38.4 percent) as well as Hispanics (39.4 percent) have the largest proportions of individuals who feel they do not speak English “very well.” 

They also have the highest proportions of foreign-born 

persons. American Indians and Alaska Natives, African Americans, and Hispanics have significantly 

higher levels of unemployment and poverty as well 

as substantially lower household incomes than Asian 

Americans, Pacific Islanders, or whites. In all four 

groups, a majority of members live in urban environments; however, American Indians and Alaska Natives 

have the lowest proportion of urban residents. 

Differences in the demographic characteristics of 

each of the various racial and ethnic groups are related 

to variations in national background and immigration 

history. Asian Americans and Pacific Islanders, for 

example, include approximately 32 different ethnic and 

Table 1. U.S. population distribution, by race/ethnicity and Hispanic origin and percentage change, 

1980–1990 

1980 

(in millions) 

1990 

(in millions) % Change 

White* 180.26 188.42 4 

African American* 26.10 29.28 12 

Hispanic 14.61 21.90† 50 

Asian American and Pacific Islander 3.50 7.23 107 

American Indian and Alaska Native‡ 1.42 2.02 42 

*Excludes persons of Hispanic origin. 

†Excludes 3.5 million Hispanics in Puerto Rico. 

‡Includes Eskimos and Aleuts.
 

Source: U.S. Bureau of the Census 1983, 1993c.
 
Introduction and Summary 9 

 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 2. Selected demographic characteristics for the U.S. population, by race/ethnicity, 1990 

African American Indians/ Asian Americans/ 

Characteristic Americans Alaska Natives Pacific Islanders Hispanics Whites*

 Women (percentage) 52.8 50.4 51.2 49.2 51.3

 Median age (years) 28.2 26.9 30.1 25.6 34.9

 Foreign born (percentage) 4.9 2.3 63.1 35.8 3.3

 Education (percentage

 of persons aged ≥25 years)

 High school education 63.1 65.5 77.5 49.8 79.1

 Bachelor’s degree or higher 11.4 9.3 36.6 9.2 22.1

 English-language ability

 (percentage of persons

 aged ≥5 years)

 Speak a language other than

 English 6.3 23.8 73.3 77.8 5.7

 Do not speak English

 “very well” 2.4 9.2 38.4 39.4 1.8

 Number of persons per family 3.5 3.6 3.7 3.8 3.0

 Percentage of families with own

 children aged <18 years 56.5 60.7 59.5 64.5 45.2

 Employment status†

 (percentage of persons

 aged ≥16 years)

 Employed 62.7 62.1 67.5 67.5 65.3

 Unemployed 12.9 14.4 5.3 10.4 5.0

 Percentage of employed

 persons aged ≥16 years in a

 managerial/professional

 occupation 18.1 18.3 30.6 14.1 28.5

 Household income in 1989 ($)

 Median 19,758 20,025 36,784 24,156 31,672

 Mean 25,872 26,602 46,695 30,301 40,646

 Per capita income in 1989 ($) 8,859 8,328 13,638 8,400 16,074

 Poverty rate (percentage)

 Families 26.3 27.0 11.6 22.3 7.0

 Persons 29.5 30.9 14.1 25.3 9.2

 Urban residents (percentage) 87.2 56.0 95.4 91.4 70.9 

Population 29,930,524 2,015,143 7,226,986 21,900,089 188,424,773

*Excludes persons of Hispanic origin. The population figures for African Americans in Tables 1 and 2 are different 

because the population cited in Table 2 includes African Americans of Hispanic origin, while the African 

American population cited in Table 1 excludes persons of Hispanic origin. 

†These figures do not include several categories of people who were not in the civilian labor force for various 

reasons, such as students, housewives, retired workers, seasonal workers in an off season who were not looking 

for work, institutionalized persons, and persons doing only incidental unpaid family work (less than 15 hours 

during the reference week). 

Source: U.S. Bureau of the Census 1993a,c. 
10 Chapter 1 

Surgeon General’s Report 

national groups and speak nearly 500 languages and 

dialects (Chen 1993). They trace their background to 

areas as diverse as Mongolia to the north, Indonesia 

and the South Pacific Islands to the south, India to the 

west, and Japan to the east. Hispanics include individuals who trace their background to the original settlers of large areas in what is now the Southwest United 

States as well as recent immigrants from any of the 18 

Spanish-speaking countries in Latin America. The 

American Indian and Alaska Native population in the 

United States is likewise composed of a richly diverse 

group of indigenous cultures, over half of whom do 

not live on a reservation (U.S. Bureau of the Census 

1993c). More than 500 federally recognized tribes and 

an additional 100 nonfederally recognized tribes are 

concentrated primarily in 25 reservation states (U.S. 

Bureau of the Census 1992a). American Indians and 

Alaska Natives continue to speak more than 150 languages. (For additional information, see U.S. Bureau 

of the Census reports on Asian Americans and Pacific 

Islanders [1993a], Hispanics [1993b], and American 

Indians and Alaska Natives [1993c].) Most African 

Americans in the United States can trace their ancestry to territories that include the modern states of 

Benin, Burkina Faso (formerly Upper Volta), 

Cameroon, the Congo Republic, Côte d’Ivoire (Ivory 

Coast), the Democratic Republic of the Congo (formerly Zaire), Gabon, Gambia, Ghana, Guinea, Liberia, 

Nigeria, Senegal, Sierra Leone, and Togo (Ploski and 

Williams 1989). The mode of entry for practically all 

Africans who entered the United States in the seventeenth, eighteenth, and nineteenth centuries (until 

1865) was as slaves (see Chapter 4 for further historical discussion). Many recent immigrants came from 

the Caribbean islands and Sub-Saharan Africa. This 

report excludes data on the 3.5 million residents of 

Puerto Rico as well as data on residents of other territories and associated states of the United States; however, many of the issues discussed in this report are 

relevant to these individuals because they have been 

influenced by the events taking place in the 50 states. 

Over the next 50 years, the population of the four 

groups is expected to increase dramatically, reaching 

close to one-half of the country’s population by the 

year 2050 (Table 3), according to estimates from the 

U.S. Bureau of the Census (1992b). These estimates 

underscore the need to develop appropriate interventions to avert disturbing tobacco addiction patterns in 

this large segment of the population. 

Table 3. Estimated percentage distribution of the U.S. population, by race/ethnicity and Hispanic origin, 

1990–2050 

Non-Hispanic 

Year 

African 

American 

Asian American/ 

Pacific Islander 

American 

Indian* White Hispanic 

1990 11.8 2.8 0.7 75.7 9.0 

1995 12.1 3.5 0.7 73.6 10.1 

2000 12.3 4.2 0.8 71.6 11.1 

2005 12.6 4.9 0.8 69.6 12.2 

2010 12.8 5.5 0.8 67.6 13.2 

2020 13.3 6.8 0.9 63.9 15.2 

2050 15.0 10.1 1.1 52.7 21.1 

*Includes Eskimos and Aleuts.
 

Source: U.S. Bureau of the Census 1992b.
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Effects of Racial/Ethnic Background on 

Health 

Extensive research has been conducted on the 

relationship between health and race/ethnicity (see, 

for example, Harwood 1981; Polednak 1989; 

Braithwaite and Taylor 1992; Young 1994). Published 

reports of these studies tend to show different rates of 

illness across racial/ethnic groups. Some of these differences may be explained by variations in each 

group’s beliefs and attitudes, traditional health-related 

practices, normative behaviors, social conditions, levels of access to high-quality health care, experiences 

with discrimination and racism, living environments, 

competing causes of death, and genetic backgrounds. 

Genetic factors may contribute to certain differences 

among groups of people; however, culture, degree of 

acculturation, and socioeconomic factors are probably 

far more significant determinants of health status in 

the United States (Freeman 1993; Adler et al. 1994). 

Culture is a broad concept (Kroeber and 

Kluckhohn 1963)—its influence encompasses all aspects of daily life, including beliefs and practices about 

health and illness as well as norms that dictate behaviors. Most contemporary societies include many different cultures, which may be defined by historical, 

geographic, economic, social, and political elements 

(Helman 1985). The United States has always been a 

nation of immigrants and coexisting cultures. 

Acculturation—the process of learning the values, beliefs, norms, and traditions of a new culture 

(Marín 1992)—allows individuals to make choices and 

to learn of new worldviews, while keeping their original views (biculturalism) or modifying their initial 

perspectives to be more consonant with those of the 

new culture (assimilation). In multicultural societies 

such as the United States, acculturation occurs among 

immigrants (as they learn the host culture) as well as 

among individuals born in the United States (as they 

learn the culture of immigrants). Despite the significance of acculturation’s link with human behavior, few 

studies have focused on how acculturation might 

affect the health status and behavior of ethnic groups 

in the United States. Part of the problem has been the 

difficulty in designing appropriate measuring instruments (Marín 1992), although recent research has 

begun to assess the role that acculturation plays in 

determining the health status of members of U.S. 

racial/ethnic groups (Pérez-Stable 1994; Vega and 

Amaro 1994; Williams and Collins 1995). 

Socioeconomic characteristics, which are powerful determinants of health and disease (USDHHS 1985, 

1991; Liberatos et al. 1988; HRSA 1991; Williams and 

Collins 1995), differ markedly among the racial and 

ethnic groups of the United States (Table 2). Levels of 

income and education may directly and indirectly affect the health status of individuals (Council on Ethical and Judicial Affairs 1990; Weissman et al. 1991). 

Income, for example, often is a determinant of access 

to health care as well as of the quantity and quality of 

health care available. Persons with low incomes, regardless of race or ethnicity, are more likely to be 

uninsured (American College of Physicians 1990), to 

encounter delays in seeking or receiving care or to be 

denied care (Tallon 1989), to rely on hospital clinics 

and emergency rooms for health services (NCHS 1985), 

and to receive substandard care (Burstin et al. 1992). 

Level of education may influence health beliefs and 

behaviors, which determine whether and how individuals seek health care, make treatment choices, and 

comply with treatment suggestions. Because the literature reviewed in this report has often failed to consider the role of socioeconomic factors in the health 

status of members of racial/ethnic groups, understanding the significance of the results is difficult. 

Nevertheless, these published reports indicate that 

access to health care and the type of care received are 

partly determined by the race and ethnicity of the patient and that members of minority groups are less 

likely than whites to receive adequate care (e.g., 

Blendon et al. 1989; CDC 1989; Todd et al. 1993; Williams and Collins 1995). 

The information summarized in this report reflects the role of race, ethnicity, and culture in shaping 

tobacco use among members of the four population 

groups. Unfortunately, currently available methods 

do not help delineate the role of acculturation, socioeconomic conditions, and societal problems such as 

racism, prejudice, and discrimination (e.g., Osborne 

and Feit 1992; Freeman 1993; Pappas 1994). Nevertheless, efforts were made here to discern the possible 

role of these variables in explaining tobacco use among 

racial/ethnic minority group members. 

Introduction and Summary 11 
 

Surgeon General’s Report 

Chapter Conclusions 

Following are the specific conclusions for each 

chapter in this report. 

Chapter 2. Patterns of Tobacco Use Among 

Four Racial/Ethnic Minority Groups 

1.	 In 1978–1995, the prevalence of cigarette smoking 

declined among African American, Asian American and Pacific Islander, and Hispanic adults. 

However, among American Indians and Alaska 

Natives, current smoking prevalence did not 

change for men from 1983 to 1995 or for women 

from 1978 to 1995. 

2.	 Tobacco use varies within and among racial/ 

ethnic groups; among adults, American Indians 

and Alaska Natives have the highest prevalence 

of tobacco use; African American and Southeast 

Asian men also have a high prevalence of smoking. Asian American and Hispanic women have 

the lowest prevalence. 

3.	 In all racial/ethnic groups discussed in this report 

except American Indians and Alaska Natives, men 

have a higher prevalence of cigarette smoking than 

women. 

4.	 In all racial/ethnic groups except African Americans, men are more likely than women to use 

smokeless tobacco. 

5.	 Cigarette smoking prevalence increased in the 

1990s among African American and Hispanic adolescents after several years of substantial decline 

among adolescents of all four racial/ethnic minority groups. This increase is particularly striking 

among African American youths, who had the 

greatest decline of the four groups during the 1970s 

and 1980s. 

6.	 Since 1978, the prevalence of cigarette smoking has 

remained strikingly high among American Indian 

and Alaska Native women of reproductive age and 

has not declined as it has among African American, Asian American and Pacific Islander, and 

Hispanic women of reproductive age. 

were among those with less formal education. 

Among women in these three groups, educationrelated declines in cigarette smoking were less 

pronounced. 

7.	 Declines in smoking prevalence were greater 

among African American, Hispanic, and white 

men who were high school graduates than they 

8.	 Educational attainment accounts for only some of 

the differences in smoking behaviors (current 

smoking, heavy smoking, ever smoking, and 

smoking cessation) between whites and the racial/ 

ethnic minority groups discussed in this report. 

Other biological, social, and cultural factors are 

likely to further account for these differences. 

9.	 Compared with whites who smoke, smokers in 

each of the four racial/ethnic minority groups 

smoke fewer cigarettes each day. Among smokers, African Americans, Asian Americans and Pacific Islanders, and Hispanics are more likely than 

whites to smoke occasionally (less than daily). 

10. The data in general suggest that acculturation influences smoking patterns in that individuals tend 

to adopt the smoking behavior of the current 

broader community; however, the exact effects of 

acculturation on smoking behavior are difficult to 

quantify because of limitations on most available 

measures of this cultural learning process. 

Chapter 3. Health Consequences of 

Tobacco Use Among Four Racial/Ethnic 

Minority Groups 

1.	 Cigarette smoking is a major cause of disease and 

death in each of the four racial/ethnic groups studied in this report. African Americans currently 

bear the greatest health burden. Differences in the 

magnitude of disease risk are directly related to 

differences in patterns of smoking. 

2.	 Although lung cancer incidence and death rates 

vary widely among the nation’s racial/ethnic 

groups, lung cancer is the leading cause of cancer 

death for each of the racial/ethnic groups studied 

in this report. Before 1990, death rates from malignant neoplasms of the respiratory system increased 

among African American, Hispanic, and American 

Indian and Alaska Native men and women. From 

12 Chapter 1 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1990 through 1995 death rates from respiratory cancers decreased substantially among African American men, leveled off among African American 

women, decreased slightly among Hispanic men 

and women, and increased among American Indian 

and Alaska Native men and women. 

3.	 Rates of tobacco-related cancers (other than lung 

cancer) vary widely among members of racial/ 

ethnic groups, and they are particularly high 

among African American men. 

4.	 The effect of cigarette smoking (as reflected by 

biomarkers of tobacco exposure) on infant birth 

weight appears to be the same in African American 

and white women. As reported in previous Surgeon General’s reports, cigarette smoking increases 

the risk of delivering a low-birth-weight infant. 

5.	 No significant racial/ethnic group differences have 

been consistently demonstrated in the relationship 

between smoking and infant mortality or sudden 

infant death syndrome (SIDS); cigarette smoking 

has been associated with increased risk of SIDS 

and remains a probable cause of infant mortality. 

6.	 Future research is needed and should focus on how 

tobacco use affects coronary heart disease, stroke, 

cancer, chronic obstructive pulmonary disease, and 

other respiratory diseases among members of 

racial/ethnic groups. Studies also are needed to 

determine how the health effects of smokeless tobacco use and exposure to environmental tobacco 

smoke vary across racial/ethnic minority groups. 

7.	 Persons of all racial/ethnic backgrounds are vulnerable to becoming addicted to nicotine, and no 

consistent differences exist in the overall severity 

of addiction or symptoms of addiction across 

racial/ethnic groups. 

8.	 Levels of serum cotinine (a biomarker of tobacco 

exposure) are higher in African American smokers than in white smokers for similar levels of daily 

cigarette consumption. Further research is needed 

to clarify the relationship between smoking practices and serum cotinine levels in U.S. racial/ 

ethnic groups. Variables such as group-specific 

patterns of smoking behavior (e.g., number of 

puffs per cigarette, retention time of tobacco smoke 

in the lungs), rates of nicotine metabolism, and 

brand mentholation could be explored. 

Chapter 4. Factors That Influence Tobacco 

Use Among Four Racial/Ethnic Minority 

Groups 

1.	 The close association of tobacco with significant 

events and rituals in the history of many racial/ 

ethnic communities and the tobacco industry’s 

long history of providing economic support to 

some racial/ethnic groups—including employment opportunities and contributions to community groups and leaders—may undermine 

prevention and control efforts. 

2.	 The tobacco industry’s targeted advertising and 

promotion of tobacco products among members 

of these four U.S. racial/ethnic groups may undermine prevention and control efforts and thus 

lead to serious health consequences. 

3.	 The high level of tobacco product advertising 

in racial/ethnic publications is problematic because the editors and publishers of these publications may omit stories dealing with the damaging 

effects of tobacco or limit the level of tobacco-use 

prevention and health promotion information included in their publications. 

4.	 Although much of the original research on psychosocial factors that influence tobacco use reflects 

general processes that may apply to racial/ethnic 

populations, documenting such generalizability 

requires further research. 

5.	 The initiation of tobacco use and early tobacco use 

among members of the various racial/ethnic minority groups seem to be related to numerous categories of variables—such as sociodemographic, 

environmental, historical, behavioral, personal, 

and psychological—although the predictive power 

of these categories or of specific risk factors is not 

known with certainty because of the paucity of 

research. 

6.	 Cigarette smoking among members of the four 

racial/ethnic groups is associated with depression, 

psychological stress, and environmental factors 

such as advertising and promotion and peers who 

smoke, as is also the case in the general population. The role of these factors in tobacco use among 

members of these racial/ethnic groups deserves 

attention by researchers and persons who develop 

smoking prevention and cessation programs. 

Introduction and Summary 13 
 

Surgeon General’s Report 

Chapter 5. Tobacco Control and Education 

Efforts Among Members of Four Racial/ 

Ethnic Minority Groups 

1.	 More research is needed on the effect of culturally 

appropriate programs to reduce tobacco use 

among racial/ethnic minority groups. Interventions should be language appropriate; addressing 

psychosocial characteristics such as depression, 

stress, and acculturation may increase the acceptance of programs by members of racial/ethnic 

groups. 

2.	 To be culturally appropriate, tobacco control programs must reflect the targeted racial/ethnic 

group’s cultural values, consider the group’s 

psychosocial correlates of tobacco use, and use 

strategies that are acceptable and credible to members of the group. Culturally competent program 

staff must be aware and accepting of cultural differences, be able to assess their own cultural values, be conscious of intercultural dynamics when 

persons of different cultures interact, be aware of 

a racial/ethnic group’s relevant cultural characteristics, and have the skills to adapt to cultural 

diversity. 

3.	 Numerous strategies are needed to control tobacco 

use among racial/ethnic youths: restricting minors’ access to tobacco products, establishing culturally appropriate school-based programs, and 

designing mass media efforts geared to young 

people’s interests, attitudes, expectations, and 

norms. Recent provisions of the Synar Amendment, designed to prevent minors’ access to tobacco products, and the FDA regulations aimed 

at reducing the access to and appeal of tobacco 

products to young people are intended to reduce 

tobacco use among all youth, including members 

of racial/ethnic minority groups. 

4.	 Members of racial/ethnic groups are less likely 

than the general population to participate in smoking cessation groups and to receive cessation advice from health care providers. Barriers to ethnic 

group participation include limited cultural competence of health care providers and a lack of transportation, money, and access to health care. 

5.	 Available data indicate that racial/ethnic groups 

support smoking restrictions, such as increasing 

cigarette excise taxes, banning cigarette advertisements, restricting access to cigarette vending machines, raising the legal age of purchase, 

prohibiting sponsorship of events by tobacco companies, and establishing clean indoor air regulations. Additional research is needed to evaluate 

how best to build on this base of public opinion 

support to strengthen existing tobacco prevention 

and control programs within racial/ethnic 

communities. 

6.	 Prevention and cessation efforts in racial/ethnic 

communities are limited by underdeveloped tobacco control infrastructures and low levels of resources for research, program development, and 

program dissemination. Greater resources are 

needed in racial/ethnic minority communities to 

build tobacco control infrastructures and to 

develop initiatives. 

14 Chapter 1 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

References 

Adler NE, Boyce T, Chesney MA, Cohen S, Folkman 

S, Kahn RL, et al. Socioeconomic status and health: the 

challenge of the gradient. American Psychologist 

1994;49(1):15–24. 

American College of Physicians. Access to health care 

[position paper]. Annals of Internal Medicine 

1990;112(9):641–61. 

Blendon RJ, Aiken LH, Freeman HE, Corey CR. Access to medical care for black and white Americans: a 

matter of continuing concern. Journal of the American 

Medical Association 1989;261(2):278–81. 

Braithwaite RL, Taylor SE, editors. Health Issues in the 

Black Community. San Francisco: Jossey-Bass Publishers, 1992. 

Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic 

status and risk for substandard medical care. Journal 

of the American Medical Association 1992;268(17): 

2383–7. 

Centers for Disease Control. Pap smear screening— 

Behavioral Risk Factor Surveillance System, 1988. 

Morbidity and Mortality Weekly Report 1989;38(45): 

777–9. 

Centers for Disease Control and Prevention. Chronic 

Disease in Minority Populations. Atlanta: Centers for 

Disease Control and Prevention, 1994. 

Chen VW. Smoking and the health gap in minorities. 

Annals of Epidemiology 1993;3(2):159–64. 

Council on Ethical and Judicial Affairs. Black-white 

disparities in health care. Journal of the American Medical Association 1990;263(17):2344–6. 

Day JC. Population Projections of the United States by Age, 

Sex, Race, and Hispanic Origin: 1995 to 2050. U.S. 

Bureau of the Census, Current Population Reports. 

Washington (DC): US Government Printing Office. 

P25-1130, 1996. 

Freeman HP. Poverty, race, racism, and survival. Annals of Epidemiology 1993;3(2):145–9. 

Harwood A, editor. Ethnicity and Medical Care. Cambridge (MA): Harvard University Press, 1981. 

Health Resources and Services Administration. Health 

Status of Minorities and Low-Income Groups. Washington (DC): US Department of Health and Human Services, Public Health Service, Health Resources and 

Services Administration, Bureau of Health Professions, 

Division of Disadvantaged Assistance. DHHS Publication No. (HRSA) HRS-P-DV 85-1, 1985. 

Health Resources and Services Administration. Health 

Status of Minorities and Low-Income Groups: Third Edition. Washington (DC): US Department of Health and 

Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health 

Professions, Division of Disadvantaged Assistance. 

GPO Publication No. 507-J-1, 1991. 

Helman C. Culture, Health and Illness: An Introduction 

for Health Professionals. Bristol (England): John Wright 

& Sons, 1985. 

Kroeber AL, Kluckhohn C. Culture: A Critical Review of 

Concepts and Definitions. New York: Vintage Books, 1963. 

Liberatos P, Link BG, Kelsey JL. The measurement of 

social class in epidemiology. Epidemiologic Reviews 

1988;10:87–121. 

Marín G. Issues in the measurement of acculturation 

among Hispanics. In: Geisinger KF, editor. Psychological Testing of Hispanics. Washington (DC): American 

Psychological Association, 1992:235–51. 

National Center for Health Statistics. Persons With and 

Without a Regular Source of Medical Care: United 

States. Data from the National Health Survey. Vital and 

Health Statistics. Series 10, No. 151. Hyattsville (MD): 

US Department of Health and Human Services, Public Health Service, National Center for Health Statistics. DHHS Publication No. (PHS) 85-1579, 1985. 

National Center for Health Statistics. Healthy People 

2000 Review, 1993. Hyattsville (MD): US Department 

of Health and Human Services, Public Health Service, 

Centers for Disease Control and Prevention, National 

Center for Health Statistics. DHHS Publication No. 

(PHS) 94-1232-1, 1994. 

Introduction and Summary 15 
 

Surgeon General’s Report 

National Heart, Lung, and Blood Institute. Minority 

Programs of the National Heart, Lung, and Blood Institute: 

Fiscal Year 1993. Bethesda (MD): US Department of 

Health and Human Services, Public Health Service, 

National Institutes of Health, National Heart, Lung, 

and Blood Institute. NIH Publication No. 94-3037, 1994. 

National Institutes of Health. Minorities in NIH Extramural Grant Programs: Fiscal Year 1982–1991. Bethesda 

(MD): National Institutes of Health, Division of Research Grants. GPO Publication No. 351-597, 1993. 

Novello AC, Soto-Torres LE. One voice, one vision— 

uniting to improve Hispanic-Latino health. Public 

Health Reports 1993;108(5):529–33. 

Osborne NG, Feit MD. The use of race in medical research [commentary]. Journal of the American Medical 

Association 1992;267(2):275–9. 

Pappas G. Elucidating the relationships between race, 

socioeconomic status, and health [editorial]. American 

Journal of Public Health 1994;84(6):892–3. 

Pérez-Stable EJ. Cardiovascular disease. In: Molina 

CW, Aguirre-Molina M. Latino Health in the US: A Growing Challenge. Washington (DC): American Public 

Health Association, 1994:247–78. 

Ploski HA, Williams J, editors. The Negro Almanac: A 

Reference Work on the African American. Detroit: Gale 

Research Inc, 1989. 

Polednak AP. Racial and Ethnic Differences in Disease. 

New York: Oxford University Press, 1989. 

Tallon JR Jr. A health policy agenda proposal for including the poor. Journal of the American Medical Association 1989;261(7):1044. 

Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk 

factor for inadequate emergency department analgesia. Journal of the American Medical Association 

1993;269(12):1537–9. 

US Bureau of the Census. Chapter C, General Social 

and Economic Characteristics. Part 1, United States 

Summary. 1980 Census of Population, Volume 1, Characteristics of the Population. Washington (DC): US Government Printing Office. Publication No. PC80-1-C1, 

1983. 

US Bureau of the Census. 1990 Census of Population, 

General Population Characteristics, United States. Washington (DC): US Department of Commerce, Economics and Statistics Administration, Bureau of the 

Census, 1992a. 

US Bureau of the Census. Population Projections of 

the United States, by Age, Sex, Race, and Hispanic 

Origin: 1992 to 2050. U.S. Bureau of the Census, Current Population Reports. Washington (DC): US Government Printing Office. P25-1092, 1992b. 

US Bureau of the Census. 1990 Census of Population: 

Asians and Pacific Islanders in the United States. Washington (DC): US Department of Commerce, Economics and Statistics Administration, Bureau of the 

Census. Publication No. CP-3-5, 1993a. 

US Bureau of the Census. 1990 Census of Population: 

Persons of Hispanic Origin in the United States. Washington (DC): US Department of Commerce, Economics and Statistics Administration, Bureau of the 

Census. Publication No. CP-3-3, 1993b. 

US Bureau of the Census. 1990 Census of Population: 

Social and Economic Characteristics, United States. Washington (DC): US Department of Commerce, Economics and Statistics Administration, Bureau of the 

Census. Publication No. CP-2-1, 1993c. 

US Department of Commerce. Directive No. 15. Race 

and ethnic standards for federal statistics and administrative reporting. In: Statistical Policy Handbook. Washington (DC): US Department of Commerce, Office of 

Federal Statistical Policy and Standards, 1978:37–8. 

US Department of Health and Human Services. Report of the Secretary’s Task Force on Black & Minority 

Health. Volume 1: Executive Summary. Washington (DC): 

US Department of Health and Human Services, 1985. 

US Department of Health and Human Services. Healthy 

People 2000: National Health Promotion and Disease Prevention Objectives. Washington (DC): US Department 

of Health and Human Services, Public Health Service. 

DHHS Publication No. (PHS) 91-50212, 1991. 

US Department of Health and Human Services. Healthy 

People 2000: Midcourse Review and 1995 Revisions. Washington (DC): US Department of Health and Human 

Services, Public Health Service, 1995. 

16 Chapter 1 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Vega WA, Amaro H. Latino outlook: good health, 

uncertain prognosis. Annual Review of Public Health 

1994;15:39–67. 

Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and 

consequences. Annals of Internal Medicine 1991;114 

(4):325–31. 

Williams DR, Collins C. US socioeconomic and racial 

differences in health: patterns and explanations. Annual Review of Sociology 1995;21:349–86. 

Young TK. The Health of Native Americans: Toward a Bicultural Epidemiology. New York: Oxford University 

Press, 1994. 

Introduction and Summary 17 

Chapter 2
 

Patterns of Tobacco Use Among Four
 

Racial/Ethnic Minority Groups
 

Introduction 21
 

Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups 22
 

African Americans 22
 

Prevalence of Cigarette Smoking 22
 

Number of Cigarettes Smoked Daily 23
 

Quitting Behavior 25
 

Women of Reproductive Age 26
 

Young People 28
 

American Indians and Alaska Natives 44
 

Prevalence of Cigarette Smoking 44
 

Number of Cigarettes Smoked Daily 45
 

Quitting Behavior 46
 

Women of Reproductive Age 48
 

Young People 49
 

Regional and Tribal Tobacco Use 50
 

Asian Americans and Pacific Islanders 56
 

Prevalence of Cigarette Smoking 56
 

Number of Cigarettes Smoked Daily 56
 

Quitting Behavior 57
 

Women of Reproductive Age 57
 

Young People 59
 

State and Local Smoking Estimates 60
 

Cigarette Smoking in Asian Countries 65
 

Hispanics 66
 

Prevalence of Cigarette Smoking 66
 

Number of Cigarettes Smoked Daily 69
 

Quitting Behavior 70
 

Women of Reproductive Age 71
 

Young People 72
 

Retrospective Analyses of Smoking Prevalence Among African Americans
 

and Hispanics 74
 

Prevalence of Cigarette Smoking Among Successive Birth Cohorts 74
 

African Americans 74
 

Hispanics 75
 

Long-Term Trends in Cigarette-Smoking Initiation 78
 

African Americans 78
 

Hispanics 78
 

Cigarette Brand Preferences 79
 
20 Chapter 2 

Surgeon General's Report

Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior 83
 

Current Smoking 85
 

Smoking Cessation 85
 

Heavy Smoking 85
 

Ever Smoking 85
 

Occasional Smoking 86
 

Exposure to Environmental Tobacco Smoke 86
 

Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use 87
 

Cigarette Smoking 87
 

Pipe and Cigar Use 91
 

Use of Smokeless Tobacco 94
 

Conclusions 94
 

Appendix 1. Sources of Data 95
 

National Health Interview Survey (NHIS) 95
 

Hispanic Health and Nutrition Examination Survey (HHANES) 95
 

Behavioral Risk Factor Surveillance System (BRFSS) 95
 

Adult Use of Tobacco Survey (AUTS) 96
 

Monitoring the Future (MTF) Surveys 96
 

Youth Risk Behavior Survey (YRBS) 96
 

Teenage Attitudes and Practices Survey (TAPS) 96
 

Appendix 2. Measures of Tobacco Use 97
 

Cigarette Smoking and Cessation 97
 

Number of Cigarettes Smoked Daily 97
 

Use of Cigars, Pipes, and Smokeless Tobacco 97
 

Appendix 3. Patterns of Cigarette Use Among Whites 98
 

Appendix 4. Patterns of Cigarette Use Among African Americans 112
 

Appendix 5. Validation of the Retrospective Assessment of Smoking Prevalence 122
 

References 125
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Introduction 

Over the past 15 years, the prevalence of cigarette smoking has generally declined among adult 

African Americans, Asian Americans and Pacific Islanders, and Hispanics. Nevertheless, rates of cigarette smoking and other tobacco use are still high 

among certain racial/ethnic minority groups compared with among the overall population, particularly 

American Indians and Alaska Natives. Designing 

more successful public health efforts to reduce tobaccorelated diseases and deaths in racial/ethnic populations requires greater understanding of these racial/ 

ethnic patterns of tobacco use. This chapter summarizes how smoking behaviors such as current tobacco 

use, cigarette consumption, and quitting behavior 

among adults vary within and among racial/ethnic 

groups. In addition, for all racial/ethnic groups, the 

prevalence of cigarette smoking is examined for two 

groups of special interest, women of reproductive age 

and adolescents. 

The purpose of this chapter is to summarize in 

one source the reported trends and patterns of tobacco 

use among members of the four racial/ethnic minority groups, by gender, age, and level of education. In 

addition, newly compiled information is presented on 

smoking patterns by birth cohort (based on year of 

birth) for African Americans and Hispanics. The relationship between racial/ethnic group and education 

as predictors of cigarette smoking is explored, and 

data on cigarette brand preference and exposure to 

environmental tobacco smoke are presented. The influence of acculturation on smoking behavior is examined among the two fastest growing immigrant 

groups to the United States—Asian Americans and 

Pacific Islanders and Hispanics. Although reports of 

the effects of acculturation vary widely in the literature, it is an important correlate of behavior despite 

limitations in conceptualization, operationalization, 

and measurement. 

The analyses presented in this chapter incorporate data from national and state-specific populationbased surveys of adults, national population-based 

surveys of adolescents, and local and international 

surveys of various adult and adolescent populations. 

The national studies cited in this chapter include the 

National Health Interview Survey (NHIS) (1978–1995), 

which garners yearly data on cigarette smoking; the 

Behavioral Risk Factor Surveillance System (BRFSS) 

(1987–1992), which collects information on behavioral 

risks among adults in the United States; the Adult Use 

of Tobacco Survey, which has been conducted periodically since 1964; the Hispanic Health and Nutrition 

Examination Survey (HHANES), which gathered demographic and cigarette-smoking information from 

Hispanics between 1982 and 1984; the Monitoring the 

Future (MTF) surveys, which have been conducted in 

high schools annually since 1975; and the Teenage 

Attitudes and Practices Survey (TAPS), conducted in 

1989 and 1993. Appendix 1 describes these major 

data sources, and Appendix 2 details the various 

measures of tobacco use. Appendix 3 presents data 

on patterns of cigarette use among whites that can be 

compared with the racial/ethnic group data presented 

in the chapter. Appendix 4 presents supplementary 

data on patterns of tobacco use among African 

Americans, and Appendix 5 describes how the authors 

validated one of the analytic techniques used to retrospectively estimate smoking prevalence. 

The analyses in this chapter update and expand 

on previous Surgeon General’s reports that describe 

tobacco use among racial/ethnic groups; most of these 

previous reports have focused on cigarette smoking 

only among African Americans (U.S. Department 

of Health, Education, and Welfare [USDHEW] 

1979; U.S. Department of Health and Human 

Services [USDHHS] 1983, 1988, 1989, 1990a). For some 

analyses reported here, small sample sizes limit the 

precision of the estimates. The patterns described 

in the text generally use point estimates, but confidence intervals presented in most tables can be referred 

to when the precision of the estimates needs to be 

defined. 

Patterns of Tobacco Use 21 
 

 

Surgeon General's Report 

Long-Term Tobacco-Use Trends and Behavior Among Racial/Ethnic Minority Groups 

African Americans 

Prevalence of Cigarette Smoking 

African American women fell from 31.4 to 22.7 percent. Although the prevalence of smoking among 

African American men remained consistently higher 

The overall prevalence of cigarette smoking than that among African American women, the genamong African Americans declined from 37.3 percent der differential in smoking prevalence narrowed over 

in 1978–1980 to 26.5 percent in 1994–1995, according the 18-year period. Similar patterns have been 

to data from the NHIS (Table 1) (National Center for observed since 1965 among both African Americans 

Health Statistics [NCHS], public use data tapes, 1978– and whites (Figure 1) (Centers for Disease Control and 

1995). Between 1978 and 1995, the prevalence of cur­ Prevention [CDC] 1994c). 

rent smoking among African American men fell from 

45.0 to 31.4 percent, whereas the prevalence among 

Magnitudes of decline in smoking prevalence 

also differed by age (Table 1). Between 1978 and 1995, 

Table 1.	 Percentage of adult African Americans who reported being current cigarette smokers,* overall and 

by gender, age, and education, National Health Interview Surveys, United States, 1978–1995 

aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 37.3 1.7 35.3 1.4 32.3 1.1 27.9 1.1 27.0 1.5 26.5 1.7 

Gender 

Men 45.0 2.5 40.2 2.2 37.6 1.8 34.1 1.8 32.4 2.5 31.4 2.7 

Women 31.4 1.8 31.4 1.7 28.0 1.4 22.9 1.3 22.6 1.6 22.7 1.9 

Age (years) 

18–34 38.7 2.8 34.7 2.1 32.0 1.7 26.0 1.7 22.1 2.2 21.0 2.4 

35–54 43.9 2.4 42.2 2.7 37.2 1.9 35.6 1.9 35.9 2.7 34.2 3.0 

>55 26.5 2.4 27.8 2.4 26.1 2.0 20.0 2.0 22.3 2.8 23.5 2.8 

Education§ 

Less than high school 36.4 2.5 38.7 2.1 36.3 2.0 33.1 2.2 34.2 3.4 34.8 3.3 

High school 42.1 2.6 39.4 2.8 38.8 2.1 33.5 1.9 31.9 2.7 31.3 3.1 

Some college 36.7 5.5 34.8 3.4 33.0 2.7 28.9 2.8 27.5 3.2 26.4 3.7 

College 34.6 6.7 28.4 4.3 19.7 3.2 17.8 2.9 18.2 4.2 16.7 3.8 

*Excludes African Americans who reported they were of Hispanic origin. For 1978–1991, current cigarette 

smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the 

time of survey that they currently smoked. For 1992–1995, current smokers include persons who reported 

smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked 

every day or on some days.

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

22 Chapter 2 
 

 

African

American

 men

African

American

 women

White

men

White

women

men

women

70 

60 

50 

40 

30 

20 

10 

0 

1965 1970 1975 1980 1985 1990 1995 

Year 

African 

American 

men 

African 

American 

women 

White 

men 

White 

women 

Percentage 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

African Americans 18–34 years of age experienced the 

largest decline in smoking prevalence, from 38.7 to 21.0 

percent, whereas African Americans aged 55 years and 

older experienced the smallest decline, from 26.5 to 

23.5 percent. In the years 1978–1980, persons 18–34 

years of age were nearly 1.5 times more likely to smoke 

than those 55 years of age or older. By 1994 and 1995, 

however, because of the differential decline in smoking prevalence, the prevalence of smoking among 

younger adults was as low as that among their older 

counterparts. 

The prevalence of cigarette smoking among African Americans decreased most among college graduates (Table 1)—a pattern that has been found in the 

nation as a whole (Pierce et al. 1989). Among African 

American college graduates, the smoking prevalence 

fell from 34.6 percent in 1978–1980 to 16.7 percent in 

1994–1995. In comparison, smoking prevalence among 

African Americans with less than 12 years of education was 36.4 percent in 1978–1980 and 34.8 percent in 

1994–1995. In the years 1978–1980, the prevalence of 

smoking varied little by level of education. However, 

by 1994 and 1995, an inverse relationship had emerged. 

As the level of education increased, the prevalence of 

cigarette smoking decreased. 

Number of Cigarettes Smoked Daily 

The percentage of African American smokers 

who reported that they were light smokers (smoking 

fewer than 15 cigarettes per day) increased from 56.0 

percent in 1978–1980 to 63.9 percent in 1994–1995, according to the NHIS data (Table 2) (NCHS, public use 

data tapes, 1978–1993). This upward trend was found 

across all sociodemographic groups, with men, persons less than 55 years of age, and college graduates 

experiencing the largest increases in light smoking. 

Throughout the 18-year period, African American women who smoked were consistently more likely 

than their male counterparts to smoke fewer than 15 

cigarettes per day (Table 2). African American smokers 18–34 years of age were slightly more likely than 

Figure 1. Trends in the prevalence of cigarette smoking among African American and white men and 

women, National Health Interview Surveys, United States, 1965–1995 

Source: National Center for Health Statistics, public use data tapes, 1965, 1966, 1970, 1974, 1976, 1977, 1978, 1979, 

1980, 1983, 1985, 1987, 1988, 1990, 1991, 1992, 1993, 1994, and 1995. 

Patterns of Tobacco Use 23 
 

 >25 cigarettes 10.4 1.7 9.4 1.6 8.4 1.2 7.5 1.2 5.6 1.3 7.6 2.1 

 >25 cigarettes 12.5 2.3 11.4 2.6 9.8 1.7 9.2 1.9 6.3 2.0 10.3 3.7 

 >25 cigarettes 8.1 2.3 7.3 1.5 6.8 1.3 5.4 1.3 4.7 1.5 4.6 1.7 

 >25 cigarettes 8.5 2.3 8.7 2.3 7.4 1.7 6.2 1.8 5.1 2.1 6.7 2.7 

 >25 cigarettes 13.2 2.7 11.3 2.5 10.2 1.7 8.5 1.9 6.3 2.1 8.9 3.6 

 >25 cigarettes 9.9 4.8 7.4 3.1 7.3 2.5 7.7 2.7 4.7 2.7 6.0 3.8 

Surgeon General's Report 

Table 2.	 Percentage of adult African American smokers* who reported smoking <15, 15–24, or >25 

cigarettes per day, overall and by gender, age, and education, National Health Interview Surveys, 

United States, 1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total

 <15 cigarettes 56.0 2.2 55.4 2.5 58.8 2.0 60.6 2.2 63.3 3.0 63.9 3.5 

15–24 cigarettes 33.6 2.2 35.2 2.4 32.8 1.9 31.9 2.1 31.1 2.8 28.4 3.2 

Gender 

Men

 <15 cigarettes 50.4 3.2 52.3 3.8 53.2 3.1 55.2 3.1 59.3 4.5 61.1 5.1 

15–24 cigarettes 37.1 3.6 36.3 3.4 37.0 3.1 35.6 3.1 34.4 4.2 28.6 4.7 

Women

 <15 cigarettes 62.2 3.2 58.6 3.1 65.0 2.7 67.1 2.6 67.9 3.8 67.1 4.2 

15–24 cigarettes 29.8 2.8 34.1 2.8 28.2 2.4 27.5 2.5 27.4 3.6 28.3 4.0 

Age (years) 

18–34

 <15 cigarettes 59.8 3.6 56.9 3.7 64.1 2.9 67.2 3.4 69.5 5.1 70.0 5.5 

15–24 cigarettes 31.7 3.3 34.4 3.3 28.5 2.7 26.6 3.2 25.5 4.8 23.3 5.3 

35–54

 <15 cigarettes 51.2 3.4 51.0 4.1 52.1 3.1 54.6 3.4 60.4 4.3 58.9 5.2 

15–24 cigarettes 35.6 3.7 37.7 3.9 37.7 3.1 36.9 3.2 33.2 4.1 32.2 4.8 

> 55

 <15 cigarettes 55.3 5.4 60.4 5.6 59.1 5.2 60.4 4.8 59.0 6.5 66.7 6.6 

15–24 cigarettes 34.8 5.6 32.3 5.9 33.6 5.0 31.9 4.7 36.3 6.4 27.3 6.0 

*Excludes African Americans who reported they were of Hispanic origin. For 1978–1991, current cigarette 

smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the 

time of survey that they currently smoked. For 1992–1995, current smokers include persons who reported 

smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked 

every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data 

were combined. 

‡

95% confidence interval. 

their older counterparts to be light smokers (except smokers who smoked fewer than 15 cigarettes per day. 

for the years 1983–1985). An association between edu- As the level of education increased, the proportion 

cation and light smoking became apparent smoking lightly also increased. 

in 1990–1991. In 1990 and beyond, among smokers, Throughout the 18-year period, the prevalence 

education was directly related to the proportion of of heavy smoking (smoking 25 or more cigarettes per 

24 Chapter 2 
 

 

 

 

 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 2. Continued 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Education§ 

Less than high school

 <15 cigarettes 53.1 4.0 56.0 4.1 57.3 3.1 57.3 3.4 57.7 5.5 56.1 6.0 

15–24 cigarettes 33.5 3.6 32.7 4.0 32.7 3.3 33.5 3.3 33.9 5.4 32.5 5.6 

>25 cigarettes 13.4 3.1 11.4 3.1 10.0 2.2 9.2 2.3 8.4 3.0 11.5 4.5 

High school

 <15 cigarettes 53.9 4.7 52.4 4.4 58.3 3.6 59.0 3.7 62.7 4.6 64.0 5.7 

15–24 cigarettes 34.9 4.8 40.6 4.1 33.2 3.5 34.8 3.6 33.4 4.4 29.2 4.9 

>25 cigarettes 11.2 3.6 6.9 2.1 8.5 1.9 6.2 1.6 3.9 1.8 6.8 3.9 

Some college

 <15 cigarettes 49.7 7.5 48.6 6.6 56.3 4.7 60.9 5.6 63.4 7.0 63.0 8.4 

15–24 cigarettes 37.6 6.1 37.4 6.8 34.7 4.7 32.2 5.5 31.0 6.8 32.2 8.2 

>25 cigarettes 12.7 5.9 14.1 5.1 9.0 3.1 6.9 2.9 5.6 3.1 4.9 2.5 

College

 <15 cigarettes 57.1 10.2 50.9 9.7 55.2 9.6 65.0 9.3 74.7 10.0 79.0 9.9 

15–24 cigarettes 34.1 9.0 35.6 10.9 38.2 9.6 24.9 7.9 20.6 9.5 18.1 9.5 

>25 cigarettes 8.8 5.5 13.5 9.4 6.7 3.4 10.1 6.7 4.7 4.0 2.9 3.5 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

day) was higher among African American men than 

among women, and it was higher among respondents 

35–54 years of age than among their younger and older 

counterparts (Table 2). No clear patterns emerged in 

the relationship between education and the prevalence 

of heavy smoking. 

Quitting Behavior 

Between 1978 and 1995, the overall prevalence 

of smoking cessation (the percentage of persons who 

have ever smoked 100 cigarettes and who have quit 

smoking) among African Americans increased from 

26.8 to 35.4 percent, according to data from the NHIS 

(Table 3) (NCHS, public use data tapes, 1978–1995). 

The prevalence of cessation generally increased over 

time across all gender, age, and education categories. 

The largest increases were among persons 55 years of 

age or older and college graduates. 

have been generally more likely to quit smoking than 

persons with less than 16 years of education. 

Throughout the 18-year period, the prevalence 

of smoking cessation remained higher among persons 

55 years of age or older than among their younger 

counterparts (Table 3). Since 1983, college graduates 

Attempts to quit smoking during the previous 

year and short-term success at quitting were measured 

in a multivariate analysis of the 1991 NHIS data (CDC 

1993). After statistical control was made for gender, 

age, education, and poverty status, African Americans 

were more likely than whites to stop smoking for at 

least one day during the previous year. However, African Americans who had stopped smoking for at least 

one day were less likely than whites to have quit for at 

least one month. 

Data from the National Cancer Institute (NCI) 

Supplement of the 1992–1993 Current Population Survey (CPS) indicate that among adults who were daily 

smokers one year before being surveyed, African 

Americans who had tried to quit for at least one day 

were slightly more likely than whites to have relapsed 

to daily smoking. African Americans were also slightly 

more likely than whites to have become occasional 

smokers (i.e., to be smoking on only some days) and 

slightly less likely to have quit smoking (Table 4) 

(U.S. Bureau of the Census, public use data tapes, 

Patterns of Tobacco Use 25 
 

 

Surgeon General's Report 

Table 3.	 Percentage of adult African American ever smokers who have quit,* overall and by gender, age, 

and education, National Health Interview Surveys, United States, 1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 26.8 1.7 30.0 1.8 31.8 1.6 36.1 1.8 37.0 2.4 35.4 2.6 

Gender 

Men 28.7 2.0 33.5 2.6 33.9 2.3 36.8 2.5 39.1 3.5 34.9 3.7 

Women 24.5 2.5 26.2 2.5 29.4 2.1 35.2 2.4 34.5 3.1 35.9 3.4 

Age (years) 

18–34 17.9 2.8 20.2 2.8 18.8 2.3 21.0 2.6 23.7 4.6 19.6 4.1 

35–54 27.7 2.6 29.5 2.9 33.1 2.6 35.2 2.6 33.2 3.4 33.1 4.0 

>55 42.3 4.0 47.0 3.6 49.2 3.0 57.3 3.6 56.8 4.4 54.7 4.4 

Education§ 

Less than high school 32.6 2.7 32.7 2.5 35.0 2.5 38.0 3.3 40.0 4.2 36.8 4.0 

High school 24.4 3.4 28.8 3.6 27.3 2.7 32.4 2.6 33.4 3.8 31.6 4.3 

Some college 32.4 5.9 35.0 4.7 36.6 4.0 38.1 4.4 39.0 5.3 37.3 6.3 

College 29.8 8.6 37.0 6.9 50.2 6.1 51.3 6.1 48.7 8.7 51.1 8.5 

*Excludes African Americans who reported they were of Hispanic origin. The prevalence of cessation is the 

percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at 

least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever 

smokers include current and former smokers. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

1992–1993). Some data suggest that African Americans may be more likely than whites to be dependent 

on nicotine (see Chapter 3, Table 18, in the section 

Racial/Ethnic Differences in Self-Reported Nicotine 

Dependence; Royce et al. 1993), although a report by 

Andreski and Breslau (1993) suggests the opposite. 

African Americans appear to have comparatively limited access to preventive health services, including 

smoking cessation services (USDHHS 1988; Hymowitz 

et al. 1991). 

(NCHS, public use data tapes, 1978–1995). Women 

who were college graduates experienced an overwhelming decline in smoking prevalence, from 37.0 

to 10.8 percent, whereas women with less than a high 

school education (<12 years) experienced a slight increase in the prevalence of current smoking, from 41.1 

to 46.3 percent. 

In the years 1978–1980, the prevalence of smoking varied little by level of education. However, by 

1994 and 1995, a marked inverse relationship between 

smoking and educational level had emerged. As the 

level of education increased, the prevalence of smoking decreased. This inverse relationship has also been 

found in other studies of women of reproductive age 

(CDC 1991a, 1994b). 

Women of Reproductive Age 

Between 1978 and 1995, the prevalence of current smoking among African American women of reproductive age (18–44 years) declined from 35.4 to 23.4 

percent, according to data from the NHIS (Table 5) 

National data on tobacco use and pregnancy are 

available from the 1967 and 1980 National Natality 

26 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 4.	 Current cigarette smoking status among persons* who reported that they were daily smokers 

1 year before being surveyed, Current Population Survey National Cancer Institute Supplement, 

1992–1993 

Currrent 

smoking 

status 

African 

Americans 

––––––––– 

% ±CI†

American 

Indians/ 

Alaska 

Natives 

–––––––––– 

% ±CI

Asian 

Americans/ 

Pacific 

Islanders 

–––––––––– 

% ±CI

Hispanics 

–––––––––– 

% ±CI

Whites 

–––––––––– 

% ±CI

Total 

–––––––––– 

% ±CI 

Smoke every day; did not 

try to quit for at least one 

day during the previous 

year 

59.8 1.5 62.8 5.5 57.8 4.4 59.8 2.3 63.1 0.5 62.5 0.5 

Smoke every day; did try 

to quit for at least one day 

during the previous year 

29.7 1.4 28.9 5.1 32.0 4.2 28.5 2.1 26.0 0.5 26.6 0.4 

Smoke on some days 5.6 0.7 3.7 2.1 4.8 1.9 5.6 1.1 3.7 0.2 4.0 0.2 

Do not smoke cigarettes; 

abstinent for 1–90 days 

2.2 0.5 1.8 1.5 2.5 1.4 2.5 0.7 3.4 0.2 3.2 0.2 

Do not smoke cigarettes; 

abstinent for 91–364 days 

2.7 0.5 2.8 1.9 2.9 1.5 3.6 0.9 3.8 0.2 3.7 0.2 

*Aged 18 years and older; N = 44,272. 

†

95% confidence interval.
 

Source: U.S. Bureau of the Census, public use data tapes, 1992–1993.
 

– 

Surveys, the 1982 and 1988 National Surveys of Family Growth, the 1985 and 1990 NHISs, the 1988 National Maternal and Infant Health Survey (NMIHS), 

and the 1992–1993 National Pregnancy and Health 

Survey. Furthermore, since 1989, national trend data 

on smoking and pregnancy have become readily available from information collected on the revised U.S. 

Standard Certificate of Live Birth, which is included 

as part of U.S. final natality statistics compiled each 

calendar year (NCHS 1992, 1993, 1994; Ventura et al. 

1994). 

among African American mothers aged ≥20 years declined from 33 percent in 1967 to 23 percent in 1980. 

The National Survey of Family Growth collected data 

in 1982 and 1988 on the smoking behavior of females 

15–44 years of age during their most recent pregnancy. 

In 1982, 29.2 percent of African American women reported smoking during their most recent pregnancy, 

compared with 23.4 percent in 1988 (Pamuk and 

Mosher 1992; Chandra 1995). More recent data from 

U.S. final natality statistics indicate that smoking rates 

for African Americans during pregnancy declined 

Among the earliest sources of national trend data from 17.1 percent in 1989 to 10.6 percent in 1995 (Table 

on smoking during pregnancy were the National Na­ 6). Smoking rates declined for African American teentality Surveys, which were administered to a national aged mothers from 1989 through 1995 but remained 

sample of married mothers of live infants born in 1967 virtually unchanged for African American adult mothand 1980 (Kleinman and Kopstein 1987; USDHHS ers aged 20–49 years during those years (NCHS 1992, 

1989). Among African American mothers <20 years 1993, 1994; Ventura et al. 1994, 1995, 1996). In general, 

of age, smoking rates remained virtually constant over African American adolescent mothers were less 

time at about 27 percent. The smoking prevalence likely to have smoked than mothers 20–49 years 

Patterns of Tobacco Use 27 
 

Surgeon General's Report 

Table 5.	 Percentage of African American women of reproductive age who reported being current cigarette 

smokers,* overall and by education, National Health Interview Surveys, United States, 1978–1995 

aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total	 35.4 2.3 34.1 2.0 30.6 1.8 25.4 1.6 23.8 2.1 23.4 2.4 

Education§ 

Less than high school 41.1 5.6 52.4 5.7 48.2 4.2 44.5 4.7 45.7 6.9 46.3 7.8 

High school 36.3 4.0 36.8 3.8 34.5 3.0 31.6 3.0 30.0 3.8 28.4 4.3 

Some college 37.1 6.8 32.3 5.0 30.6 3.8 26.4 3.4 26.2 4.7 26.1 5.6 

College 37.0 10.2 21.8 6.5 20.0 4.3 17.3 4.3 13.1 5.0 10.8 4.9 

*Excludes African American women who reported they were of Hispanic origin. For 1978–1991, current 

cigarette smokers include women aged 18–44 years who reported smoking at least 100 cigarettes in their lives 

and who reported at the time of survey that they currently smoked. For 1992–1995, current smokers include 

women aged 18–44 years who reported smoking at least 100 cigarettes in their lives and who reported at the 

time of survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

old—a finding that is consistent with previously 

published data (USDHHS 1994). 

Data from the 1988 NMIHS indicate that 27 percent of African American mothers sampled reported 

smoking cigarettes in the 12 months before delivery 

(Sugarman et al. 1994). The National Pregnancy and 

Health Survey, conducted between October 1992 and 

August 1993 and sponsored by the National Institute 

on Drug Abuse (NIDA), provides nationally representative data on the prevalence of prenatal drug use 

among females of reproductive age (15–44 years). According to the National Pregnancy and Health Survey, 

19.8 percent of African American women reported using cigarettes during their pregnancies (NIDA 1994). 

In the 1985 and 1990 NHISs, questions related to smoking were asked of women aged 18–44 years who had 

given birth within the past five years. In 1985, 27.5 

percent of African American women smoked during 

the 12 months before the birth and 22.6 percent smoked 

after learning of their pregnancy; in 1990, 19 percent 

smoked during the year before the birth and 14.1 percent after learning of their pregnancy (Floyd et al. 

1993). 

Young People 

Cigarette Smoking 

In the 1970s and 1980s, the prevalence of cigarette smoking declined among both male and female 

African American high school seniors, according to 

data from the MTF surveys (Figure 2) (Bachman et al. 

1991b). The prevalence of daily cigarette smoking, 

based on two-year rolling averages (percentages calculated by averaging the data for the specified year 

and the previous year to increase racial subgroup 

sample sizes and stabilize estimates), among African 

American high school seniors was 24.9 percent in 1977, 

4.1 percent in 1993, and 7.0 percent in 1996 (Figure 3) 

(Johnston et al. 1996; Institute for Social Research, 

University of Michigan, unpublished data from the 

1996 MTF surveys). Between 1974 and 1991, significant declines in the prevalence of cigarette smoking 

also were observed among African American adolescents participating in the National Household Surveys 

on Drug Abuse (NHSDAs) as well as among African 

Americans 18 and 19 years of age who participated in 

the NHISs (Nelson et al. 1995). 

28 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 6.	 Percentage of live-born infants’ mothers who reported smoking during pregnancy, by year and race/ 

ethnicity, U.S. final natality statistics, 1989–1995 

1989 1990 1991 1992 1993 1994 1995 

Race of mother* 

African American 17.1 15.9 14.6 13.8 12.7 11.4 10.6 

American Indian and Alaska Native 23.0 22.4 22.6 22.5 21.6 21.0 20.9 

Asian American and Pacific Islander† 5.7 5.5 5.2 4.8 4.3 3.6 3.4 

Chinese 2.7 2.0 1.9 1.7 1.1 0.9 0.8 

Filipino 5.1 5.3 5.3 4.8 4.3 3.7 3.4 

Hawaiian and part Hawaiian 19.3 21.0 19.4 18.5 17.2 16.0 15.9 

Japanese 8.2 8.0 7.5 6.6 6.7 5.4 5.2 

Other Asian American or 4.2 3.8 3.8 3.6 3.2 2.9 2.9

 Pacific Islander 

White 20.4 19.4 18.8 17.9 16.8 15.6 15.0 

Hispanic origin of mother‡ 

Hispanic origin 8.0 6.7 6.3 5.8 5.0 4.6 4.3 

Cuban 6.9 6.4 6.2 5.9 5.0 4.8 4.1 

Central and South American 3.6 3.0 2.8 2.6 2.3 1.8 1.8 

Mexican American 6.3 5.3 4.8 4.3 3.7 3.4 3.1 

Other and unknown Hispanic 12.1 10.8 10.7 10.1 9.3 8.1 8.2 

Puerto Rican 14.5 13.6 13.2 12.7 11.2 10.9 10.4 

African American, non-Hispanic 17.2 15.9 14.6 13.8 12.7 11.5 10.6 

White, non-Hispanic 21.7 21.0 20.5 19.7 18.6 17.7 17.1 

Total 19.5 18.4 17.8 16.9 15.8 14.6 13.9 

*Includes data for 43 states and the District of Columbia (DC) in 1989, 45 states and DC in 1990, and 46 states and 

DC in 1991–1995. Excludes data for California, Indiana, New York (but includes New York City), and South 

Dakota in 1994 and 1995; Oklahoma in 1989–1990; and Louisiana and Nebraska in 1989, which did not require the 

reporting of mother’s tobacco use during pregnancy on the birth certificate. White and African American racial 

groups include persons of Hispanic and non-Hispanic origin. 

†

Maternal tobacco use during pregnancy was not reported on the birth certificates in California and New York, 

which together accounted for 43–66 percent of the births in each Asian subgroup (except Hawaiian) during 

1989–1991. 

‡

Includes data for 42 states and DC in 1989, 44 states and DC in 1990, 45 states and DC in 1991–1992, and 46 states 

and DC in 1993–1995. Excludes data for California, Indiana, New York (but includes New York City), and South 

Dakota in 1994 and 1995; Oklahoma in 1989–1990; and Louisiana and Nebraska in 1989, which did not require the 

reporting of either Hispanic origin of mother or tobacco use during pregnancy on the birth certificate. Persons of 

Hispanic origin may be of any race. 

Sources: National Center for Health Statistics 1996; Ventura et al. 1996, 1997. 

The prevalence of cigarette smoking among African American adolescents has been substantially 

lower than the prevalence among white and Hispanic 

adolescents (Figures 2 and 3) (Bachman et al. 1991b; 

USDHHS 1994; CDC 1996; Johnston et al. 1996). Local, more limited surveys have also shown similar 

differences in cigarette smoking prevalence between 

African American and white youths (for example, 

Sheridan et al. 1993; Greenlund et al. 1996). 

In addition to the slight increases in the 1990s in 

smoking prevalence among African American high 

school seniors (Figures 2 and 3), CDC’s Youth Risk 

Behavior Survey (YRBS) detected an increase in the 

prevalence of cigarette smoking from 1991 to 1995 

Patterns of Tobacco Use 29 
 Percentage 

35 

30 

25 

20 

15 

10 

5 

0 

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 

Year 

African American males African American females White males White females 

Surgeon General's Report 

Figure 2. Trends in daily smoking* among African American and white high school seniors,

 by gender, United States, 1977–1996 

Note: To increase racial subgroup sample sizes and stabilize estimates, the percentages were calculated
 

by averaging the data for the specified year and the previous year.
 

*Daily smoking is defined as smoking one or more cigarettes per day during the previous 30 days.
 

Source: Institute for Social Research, University of Michigan, unpublished data from the Monitoring the
 

Future surveys, 1976–1996. 

among male African American high school students 

(CDC 1996). The prevalence of previous-month 

smoking among African American male high school 

students increased from 14.1 percent in 1991 to 27.8 

percent in 1995. Among female African American high 

school students, prevalence was 11.3 percent in 1991 

and 12.2 percent in 1995 (CDC 1996). Data from the 

MTF surveys indicate that the prevalence of daily 

smoking increased more rapidly from 1993 to 1996 for 

male than for female African American high school 

seniors (Figure 2) (Institute for Social Research, 

University of Michigan, unpublished data from the 

MTF surveys, 1976–1996). Yet even with this increase, 

the prevalence of smoking among African American 

high school seniors was still lower than that for 

members of other racial/ethnic groups during 1990– 

1994 (Table 7). 

The trend of lower smoking prevalences among 

African American adolescents observed in recent years 

has continued as these individuals age and become 

young adults, according to the NHIS data. From 1978 

through 1995, the prevalence of current smoking declined more among African Americans aged 20–24 years 

than among whites of the same ages, regardless of gender (Table 8) or level of formal education (Table 9) 

(NCHS, public use data tapes, 1978–1995). In addition, 

among persons 25–29 and 30–34 years of age, recent 

declines in smoking prevalence were greater for African Americans than for whites (Table 8) (Figure 4). 

In addition to the recent increases seen among 

African American high school seniors (Figures 2 and 

3), the MTF surveys indicate that previous-month 

smoking prevalence (based on two-year rolling averages) among eighth-grade African American students 

30 Chapter 2 
 

Percentage 

35 

30 

25 

20 

15 

10 

5 

0 

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 

Year 

African Americans Hispanics Whites 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Figure 3. Trends in daily smoking* among African American, Hispanic, and white high school

 seniors, United States, 1977–1996 

Note: To increase racial subgroup sample sizes and stabilize estimates, the percentages were calculated by
 

averaging the data for the specified year and the previous year.
 

*Daily smoking is defined as smoking one or more cigarettes per day during the previous 30 days.
 

Sources: Johnston et al. 1996; Institute for Social Research, University of Michigan, unpublished data, 1996.
 

increased from 5.3 percent in 1992 to 9.6 percent in 

1996; among ninth-grade African American students, 

the prevalence increased from 6.6 percent in 1992 to 

12.2 percent in 1996 (Johnston et al. 1996; Institute for 

Social Research, University of Michigan, unpublished 

data from the 1996 MTF surveys). These recent patterns among African American adolescents suggest 

that the progress seen among young adults (Table 8) 

may reverse itself in the future. 

Possible biases. The accuracy of the finding that 

African American youths have been smoking less than 

white youths has been called into question. For example, trends observed may have resulted from artifactual phenomena such as differential dropout rates 

or misclassification bias. 

Differential dropout rates. Some investigators have 

hypothesized that the data may be biased for two reasons. First, the data from school-based surveys exclude 

youths who are school dropouts. Second, because 

African American youths have a higher dropout rate 

than do white youths, the smoking prevalence rates 

may be more biased for African American youths than 

for white youths. However, this bias should only be 

apparent in the school surveys. The proportion of 

young adults (aged 25–29 years) who have completed 

at least four years of high school increased from 74 

percent in 1976 to 83 percent in 1993 for African Americans; for whites, this proportion was 86 percent in 1976 

and 87 percent in 1993 (Kominski and Adams 1994). 

The increasing rate of completing at least four years of 

high school among African American young adults, 

relative to whites, is not consistent with the hypothesis that the trend in smoking prevalence observed in 

school surveys is related to the dropout rate. Furthermore, in household surveys, the trends in smoking prevalence among African Americans have also 

Patterns of Tobacco Use 31 
 

Surgeon General's Report 

Table 7.	 Trends in the percentage of high school seniors who were previous-month smokers, by race/ 

ethnicity and gender, Monitoring the Future surveys, United States, 1976–1979, 1980–1984, 

1985–1989, 1990–1994 

1976–1979 1980–1984 1985–1989 1990–1994 

Males 

African American 33.1 19.4 15.6 11.6 

American Indian and Alaska Native 50.3 39.6 36.8 41.1 

Asian American and Pacific Islander 20.7 21.5 16.8 20.6 

Hispanic 30.3 23.8 23.3 28.5 

White 35.0 27.5 29.8 33.4 

Females 

African American 33.6 22.8 13.3 8.6 

American Indian and Alaska Native 55.3 50.0 43.6 39.4 

Asian American and Pacific Islander 24.4 16.0 14.3 13.8 

Hispanic 31.4 25.1 20.6 19.2 

White 39.1 34.2 34.0 33.1 

Note: The Institute for Social Research usually reports the N (weighted), which is approximately equal to the 

sample size. Cases are weighted to account for differential probability of selection and then normalized to average 

1.0. For males, the ranges of the N (weighted) for each of the cells in this table are 2,916–4,393 for African 

Americans, 342–587 for American Indians and Alaska Natives, 242–1,166 for Asian Americans and Pacific Islanders, 

893–2,808 for Hispanics, and 24,931–31,954 for whites. For females, the ranges of the N (weighted) for each of the 

cells in this table are 3,982–5,716 for African Americans, 299–586 for American Indians and Alaska Natives, 

223–1,143 for Asian Americans and Pacific Islanders, 940–2,723 for Hispanics, and 25,627–31,933 for whites. 

Sources: Bachman et al. 1991a; Institute for Social Research, University of Michigan, unpublished data. 

become lower than those for whites (Nelson et al. 1995). 

Finally, data from the 1989 TAPS have shown that African American youths—both active students and 

dropouts—are significantly less likely than white 

youths to have smoked recently. Among students 17 

and 18 years of age who remained in school, African 

Americans (5.7 percent) were less likely than whites 

(19.3 percent) to have smoked in the previous week 

(CDC 1991b). Among youths who left school, 17.1 

percent of African Americans and 46.1 percent of 

whites had smoked in the previous week. Similarly, 

1991 NHSDA data show that among youths 16–18 

years old, 7.2 percent of African American high school 

seniors and 27.7 percent of white high school seniors 

had smoked in the previous month, compared with 

30.4 percent of African American dropouts and 72.2 

percent of white dropouts (Kopstein and Roth 

1993). Thus, dropout status does not account for the 

lower smoking prevalence among African American 

youths. 

Differential misclassification bias. Other researchers have proposed that in recent years, African American youths may have been more likely to misclassify 

their smoking status when questioned. No trend data 

are available on differences in misclassification of 

smoking status over time between African Americans 

and whites. However, data from the 1976–1992 MTF 

surveys have been used to compare the trends of high 

school seniors’ reports of smoking by their friends—a 

measure for which they would have little reason to 

underreport (Johnston et al. 1993b; USDHHS 1994). 

Until 1993, the percentage of African American seniors 

who reported that most or all of their friends smoke 

declined substantially more than that of white seniors. 

Since 1993, an increase in this measure has been observed for African Americans, but not for whites 

(Bachman et al. 1980a, 1980b, 1981, 1984, 1985, 1987, 

1991a, 1993a, 1993b, 1997; Johnston et al. 1980a, 1980b, 

1982, 1984, 1986, 1991, 1992, 1993a, 1995b, 1997). This 

observation may be limited by the fact that African 

American and white youths have friends from several 

ethnic groups. 

Bauman and Ennett (1994) recently assessed 

misclassification bias in a household survey of adolescents 12–14 years of age, using carbon monoxide 

and salivary cotinine (a nicotine metabolite) as biological 

32 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 8.	 Percentage of African Americans and whites 20–34 years of age who reported being current 

cigarette smokers,* by age group and gender, National Health Interview Surveys, United States, 

1978–1995 aggregate data 

Characteristic 

1978–1980† 

–––––––––– 

% ±CI‡

1983–1985† 

–––––––––– 

% ±CI

1987–1988† 

–––––––––– 

% ±CI

1990–1991† 

–––––––––– 

% ±CI 

1992–1993† 

–––––––––– 

% ±CI 

1994–1995† 

–––––––––– 

% ±CI 

Aged 20–24 years 

African Americans 

Total 37.3 4.3 32.0 3.6 24.7 2.9 16.8 2.7 15.0 4.1 13.7 3.9 

Men 44.8 6.8 31.6 6.2 25.4 5.0 21.3 4.8 20.3 7.6 19.6 7.3 

Women 31.8 4.4 32.3 3.8 24.1 3.3 13.1 2.5 10.7 3.4 8.9 3.3 

Whites 

Total 35.6 1.6 35.5 1.6 30.4 1.5 28.4 1.5 32.0 2.3 33.3 2.5 

Men 37.2 2.2 34.1 2.3 30.5 2.3 28.0 2.3 32.2 3.1 34.9 3.6 

Women 34.0 2.0 36.8 2.2 30.3 1.8 28.8 2.0 32.4 3.1 31.6 3.3 

Aged 25–29 years 

African Americans 

Total 41.5 3.9 39.0 3.9 38.3 3.4 30.5 3.3 21.7 3.6 21.0 4.3 

Men 47.6 4.9 41.6 6.2 43.1 5.5 35.9 5.7 21.3 5.9 22.6 7.6 

Women 36.5 5.8 36.8 4.6 34.3 3.7 26.1 3.6 22.1 4.5 19.6 5.3 

Whites 

Total 38.4 1.4 36.2 1.5 34.7 1.3 30.8 1.3 31.2 1.9 32.2 2.1 

Men 42.3 2.0 38.3 2.2 34.5 1.8 31.2 1.9 31.9 2.7 32.6 3.1 

Women 34.7 2.0 34.1 1.9 35.0 1.7 30.5 1.7 30.6 2.5 31.9 2.8 

Aged 30–34 years 

African Americans 

Total 43.0 5.1 40.8 4.5 41.0 3.1 36.5 3.0 34.2 4.2 31.9 4.3 

Men 50.2 8.2 45.5 7.1 43.6 5.1 38.9 4.8 38.3 6.9 31.2 6.8 

Women 37.5 6.0 37.1 4.6 38.9 3.6 34.5 3.6 30.8 4.9 32.5 5.7 

Whites 

Total 38.6 1.8 34.4 1.5 33.1 1.3 31.1 1.2 32.9 1.7 30.7 1.8 

Men 43.1 2.5 37.3 2.2 35.9 1.8 32.7 1.7 33.1 2.4 31.3 2.6 

Women 34.2 2.3 31.5 1.9 30.4 1.6 29.6 1.5 32.7 2.2 30.2 2.6 

*For 1978–1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their 

lives and who reported at the time of survey that they currently smoked. For 1992–1995, current smokers 

include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of 

survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

markers for tobacco use. Among adolescents who reported that they did not smoke, African Americans 

were more likely than whites to test positive for carbon monoxide and for cotinine. Overall, however, 

white adolescents were three times more likely than 

African American adolescents to test positive for carbon monoxide, suggesting that whites in this study 

were substantially more likely to smoke, regardless of 

Patterns of Tobacco Use 33 
 

Surgeon General's Report 

Table 9.	 Percentage of African Americans and whites 20–24 years of age who reported being current 

cigarette smokers,* by education and gender, National Health Interview Surveys, United States, 

1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

>12 years’ education 

African Americans 

Total 41.9 5.2 38.6 4.5 30.4 3.7 22.8 3.9 18.5 5.4 16.7 5.4 

Men 49.1 7.9 38.2 7.7 29.6 6.3 28.9 6.9 21.9 9.4 22.2 10.1 

Women 35.9 6.3 38.9 4.9 31.0 4.5 17.8 3.5 15.2 5.1 12.5 5.0 

Whites 

Total 45.2 1.8 48.3 2.3 44.2 2.1 40.5 2.4 46.9 3.2 45.4 4.2 

Men 47.8 2.8 47.8 3.5 46.2 3.2 40.5 3.4 47.5 4.8 47.1 5.8 

Women 42.7 2.6 48.7 2.9 42.3 2.8 40.5 3.1 46.4 4.5 43.6 5.6 

>13 years’ education 

African Americans 

Total 26.4 6.4 17.3 4.4 12.4 3.7 7.2 2.9 9.0 5.3 9.3 5.6 

Men 32.0 11.3 15.6 7.9 13.3 7.0 9.2 5.3 16.6 12.4 15.9 10.6 

Women 23.5 6.7 18.5 6.6 11.9 4.0 5.5 3.0 4.6 4.0 3.1 3.0 

Whites 

Total 21.6 2.0 18.2 1.8 15.4 1.5 16.0 1.5 19.0 2.6 23.6 2.8 

Men 22.0 2.5 15.8 2.4 14.0 2.0 14.5 2.4 17.6 3.5 24.6 4.2 

Women 21.2 2.5 20.5 2.6 16.7 2.1 17.3 2.1 20.3 3.5 22.7 3.8 

*

For 1978–1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their 

lives and who reported at the time of survey that they currently smoked. For 1992–1995, current smokers 

include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of 

survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

differential misclassification. In a study of young 

adults 18–30 years old, Wagenknecht and colleagues 

(1992) also found differential misclassification, with 

African Americans (5.7 percent) more likely than 

whites (2.8 percent) to misclassify themselves as nonsmokers. However, these researchers suggested that 

their results may have been influenced by differential 

exposure to environmental tobacco smoke and by differences in nicotine metabolism. Using a sample of 

seventh- through tenth-grade New York State public 

school students, Wills and Cleary (1997) compared selfreports of cigarette smoking with measured carbon 

monoxide from expired air. The investigators found 

that the sensitivity for self-reports was slightly lower 

for African Americans than for whites, but the magnitude of the effect was small. When self-reported smoking rates were adjusted for carbon monoxide values, 

at every grade level African American students had 

significantly lower smoking prevalences than whites. 

Although the phenomenon of differential misclassification may need further investigation, no evidence indicates that misclassification bias explains the 

34 Chapter 2 
 

African Americans 

0 

10 

20 

30 

40 

50 

Percentage 

1978–80 1983–85 1987–88 1990–91 1992–93 1994–95 

Year 

Whites 

0 

10 

20 

30 

40 

50 

Percentage 

1978–80 1983–85 1987–88 1990–91 1992–93 1994–95 

Year 

Aged 20–24 Aged 25–29 Aged 30–34 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Figure 4. Trends in smoking* among African Americans and whites aged 20–34 years, United States, 

1978–1995 

*For 1978–1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in 

their lives and who reported at the time of survey that they currently smoked. For 1992–1995, current 

smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the 

time of survey that they currently smoked every day or on some days. 

Source: National Health Interview Surveys, National Center for Health Statistics, public use data tapes, 

1978–1995; see Table 8 for corresponding data. 

Patterns of Tobacco Use 35 
 

 

Surgeon General's Report 

substantial decline in smoking prevalence reported by 

African American youths. 

Possible behavioral, sociodemographic, and 

attitudinal explanations. Exploring possible interactions between the use of alcohol or other drugs and 

changes in cigarette smoking among African American 

and white adolescents may yield important scientific 

data. Understanding the trends of smoking behavior 

in the context of factors such as the age when youths 

start smoking, background and lifestyle factors, and 

attitudes about smoking may help program developers design better smoking prevention and control interventions for these and other population subgroups. 

Differential use of other drugs. MTF data were analyzed to explore possible interactions between the use 

of alcohol or other drugs and changes in cigarette 

smoking among African American and white adolescents (Table 10) (Figures 5 and 6) (Institute for Social 

Research, University of Michigan, public use data 

tapes, 1976–1994). Between 1976 and 1994, the percentage of African American adolescents who were 

abstinent from (i.e., did not use in the previous month) 

both cigarettes and other substances (Table 10) was 

higher than for whites and tended to increase more 

rapidly for African Americans than for whites in every category of drug use. For example, 41.7 percent of 

African American high school seniors surveyed in 

1976–1979 were abstinent from cigarettes and alcohol, 

compared with 64.1 percent in 1990–1994. Among 

white seniors, 22.4 percent were abstinent from both 

cigarettes and alcohol in 1976–1979, compared with 

37.1 percent in 1990–1994. Concurrent use (i.e., use of 

both substances in the past month) was lower and 

tended to decrease more rapidly among African American seniors than among white seniors between 1976 

and 1994. In addition, trends in the use of cigarettes, 

alcohol, and other substances among high school seniors indicate that among both smokers and nonsmokers, African Americans were generally less likely than 

whites to use substances other than tobacco (Table 10). 

Age of smoking initiation. African American smokers initiate smoking at slightly later ages than white 

smokers, according to the findings of two national 

studies (Escobedo et al. 1990; CDC 1991c). In addition, data from the 1994–1995 (combined) NHSDAs 

indicate that among U.S. adults aged 30–39 years who 

had ever smoked daily, the average ages for first trying a cigarette and for becoming a daily smoker were 

about one year higher for African American males than 

for white males and about two years higher for African 

American females than for white females (Table 11) 

(USDHHS, Substance Abuse and Mental Health Services 

Administration, public use data tapes, 1994–1995). 

These differences in the age of smoking initiation are not large enough to suggest that the differences in smoking prevalence currently observed 

among African American and white adolescents will 

disappear as these populations age (CDC 1991c). The 

data presented in Table 11 and by Escobedo and colleagues (1990) indicate that although African Americans are more likely than whites to begin smoking in 

their early 20s, virtually all smokers in both groups 

have begun by age 25. Furthermore, the prevalence 

of cigarette smoking has decreased more rapidly 

for African Americans than for whites among those 

persons aged 20–24 years, 25–29 years, and 30–34 

years (Table 8), suggesting that a birth cohort effect 

has occurred. 

Background and lifestyle factors. Investigations of 

background and lifestyle factors have not identified 

characteristics that might account for the greater decline in smoking among African American youths. 

Wallace and Bachman (1991) analyzed the MTF data 

and found that the difference was not explained 

by factors such as parents’ education, presence of 

two parents in the household, location of residence, 

college plans, academic performance, employment 

status, religiousness, or political views. To assess the 

incidence of cigarette smoking among African American and white adolescents, Faulkner and colleagues 

(1996) analyzed longitudinal data from the 1989–1993 

TAPS. The analyses were restricted to 3,531 African 

Americans and whites aged 11–17 years who reported 

in 1989 that they had never tried cigarettes. After 

controlling statistically for variables that were 

sociodemographic (sex, age, and parental education), 

environmental (household smoking and number of 

same-sex friends who smoke), personal (beliefs about 

the perceived benefits of smoking), and behavioral (intention to smoke, participation in organized physical 

activity, and academic performance), the study found 

that African Americans were significantly less likely 

than whites to have tried cigarette smoking four years 

later. 

Lowry and colleagues (1996) analyzed crosssectional data on 6,321 adolescents (aged 12–17 years) 

from the YRBS supplement to the 1992 NHIS. African 

Americans were significantly less likely than whites 

to have smoked in the previous 30 days. This analysis 

controlled statistically for the educational level of the 

responsible adult, for family income, for the age and 

sex of the adolescent, and for whether the adolescent 

was in or out of school. 

Furthermore, the major declines in smoking 

reported for African American high school seniors 

have occurred regardless of parents’ education; the 

36 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 10.	 Percentage of African American and white high school seniors who reported recently using or 

not using cigarettes and other selected substances,* Monitoring the Future surveys, United 

States, 1976–1994 aggregate data 

Characteristic 

1976–1979 

Yes No 

Cigarette use among African Americans† 

1980–1984 

Yes No 

1985–1989 

Yes No 

1990–1994 

Yes No 

Alcohol use 

Yes 22.7 25.9 15.2 31.2 11.0 29.5 7.2 26.2 

No 9.7 41.7 5.3 48.4 3.1 56.4 2.6 64.1 

Marijuana use 

Yes 17.2 11.9 11.2 14.2 6.4 7.8 3.1 5.8 

No 15.0 55.9 9.3 65.3 7.6 78.2 6.6 84.5 

Cocaine use 

Yes 1.4 0.6 1.4 1.3 1.0 1.0 0.3 0.2 

No 31.7 66.3 19.7 77.6 13.3 84.8 9.6 89.8 

Any illicit drug use‡ 

Yes 17.6 12.9 11.4 15.2 6.6 9.3 3.3 6.8 

No 14.0 55.5 8.8 64.6 7.0 77.1 6.2 83.7 

Cigarette use among whites§ 

1976–1979 

Yes No 

1980–1984 

Yes No 

1985–1989 

Yes No 

1990–1994 

Characteristic Yes No 

Alcohol use 

Yes 33.7 40.5 28.2 46.0 28.6 40.9 27.5 29.7 

No 3.3 22.4 2.7 23.1 3.6 26.8 5.7 37.1 

Marijuana use 

Yes 22.4 13.7 16.9 12.8 14.4 8.1 11.8 4.4 

No 14.3 49.6 13.8 56.5 17.5 60.0 21.3 62.5 

Cocaine use 

Yes 2.6 1.1 3.5 2.0 3.4 1.4 1.2 0.2 

No 34.3 62.0 27.3 67.2 28.5 66.6 31.9 66.7 

Any illicit drug use‡ 

Yes 23.3 14.8 18.9 15.5 16.1 10.0 13.3 5.9 

No 13.3 48.6 11.7 53.9 15.7 58.3 19.6 61.2 

*Refers to use of these substances in the last 30 days.

†

Entries are percentages of the entire African American high school senior population.

‡

Any illicit drug use includes any use of marijuana, hallucinogens, cocaine, or heroin or any use of other
 

opiates, stimulants, barbiturates, methaqualone, or tranquilizers not under a physician’s orders. Methaqualone is excluded from the definition of illicit drugs for the 1990–1994 survey data.
 

§

Entries are percentages of the entire white high school senior population.
 

Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data tapes,
 

1976–1994.
 

Patterns of Tobacco Use 37 
 

Surgeon General's Report 

Figure 5. Use of cigarettes and alcohol* among African American and white high school seniors, 

United States, 1976–1979 and 1990–1994 

African 

Americans 

Whites 

3% 6%

41% 

1976–1979 1990–1994 

7% 3% 

26% 

23% 

10% 

42% 

34% 

22% 

64% 

26% 

Cigarettes 

and alcohol 

Cigarettes 

but no alcohol 

No cigarettes 

but alcohol 

37% 

28% 

Neither 

30% 

*In the previous month. 

Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data 

tapes, 1976–1994; see Table 10 for corresponding data. 

respondent’s personal income; school performance; the 

importance of religion to the respondent; geographic 

region of residence; and, except for those who were 

raised on a farm, the locale in which the respondent 

grew up (Table 12) (Institute for Social Research, University of Michigan, public use data tapes, 1976–1994). 

Attitudes about smoking. One possible explanation is that the attractiveness (or functional value) of 

cigarette smoking has decreased more rapidly among 

African American high school seniors than among 

white seniors. For example, African American seniors 

have, over time, become increasingly more likely than 

white seniors to acknowledge the health risks of cigarette smoking, to claim that smoking is a dirty habit, 

and to claim that they prefer to date nonsmokers. From 

1976 through 1989, African Americans were more likely 

than whites to disagree with the statement, “I personally don’t mind being around people who are smoking” (USDHHS 1994). 

African American youths also have been less 

likely than white youths to believe that cigarette smoking helps control weight. In anonymous surveys 

of 659 students (with an average age of 16 years) 

from two racially integrated high schools in the area 

38 Chapter 2 
 

1976–1979	 1990–1994 

Cigarettes 

and illicit drugs 

Cigarettes but 

African 

Americans 

13% 

56% 

84% 

18% 

14% 

6% 3% 

7% 

no illicit drugs 

No cigarettes 

but illicit drugs 

Neither 

Whites 

61% 

15% 

49% 

23% 

20% 

13% 

6% 

13% 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Figure 6.	 Use of cigarettes and illicit drugs* among African American and white high school seniors, 

United States, 1976–1979 and 1990–1994 

*In the previous month.
 

Source: Survey Research Center, Institute for Social Research, University of Michigan, public use data 


tapes, 1976–1994; see Table 10 for corresponding data. 

of Memphis, Tennessee, 46 percent of white females, 

30 percent of white males, 10 percent of African American females, and 14 percent of African American males 

endorsed the statement, “Smoking cigarettes can help 

you control your weight/appetite” (Camp et al. 1993). 

When respondents who smoked at least once a week 

were asked whether they had smoked to control their 

weight, 61 percent of the white girls and 16 percent of 

the white boys said that they had smoked to control 

their weight, whereas none of the African American 

smokers reported that they smoked to control their 

weight. Further research is needed to delineate the 

role of weight control concerns in patterns of cigarette 

smoking initiation among adolescents of ethnic groups. 

One recent study suggests that African American adolescent females prefer a significantly heavier ideal body 

size than white adolescent females (Parnell et al. 1996), 

a finding consistent with the notion that the potential 

weight-controlling effects of cigarettes have less functional utility among young African American females 

than among white females. 

A previous Surgeon General’s report indicated that parental concern about whether an adolescent smoked appeared to decrease the risk of that 

Patterns of Tobacco Use 39 
 

Surgeon General's Report 

Table 11.	 Cumulative percentages of recalled age at which a respondent first tried a cigarette and began 

smoking daily, among African American, Hispanic, and white men and women aged 30–39, 

National Household Surveys on Drug Abuse, United States, 1994–1995 

All men* 

Age	 

(years)	 

First tried a cigarette Began smoking daily 

African 

American 

African 

Hispanic White American Hispanic White 

<12 7.0 9.2 14.9 1.4 1.4 1.3 

<14 17.1 20.6 32.2 3.7 4.6 4.6 

<16 34.8 39.0 51.0 10.9 11.2 11.8 

<18 55.1 54.7 68.7 20.3 19.6 26.4 

<19 59.9 62.7 74.0 25.5 26.3 34.3 

<20 64.6 65.5 76.1 28.6 28.4 38.5 

<25 71.5 72.9 80.9 40.5 37.2 47.4 

<30 74.3 76.4 81.7 44.6 42.5 48.8 

<39 75.1 76.7 82.5 45.1 43.4 49.9 

Mean age	 NA NA NA NA NA NA 

All women† 

Age	 

(years)	 

First tried a cigarette Began smoking daily 

African 

American 

African 

Hispanic White American Hispanic White 

<12 4.6 3.5 7.8 0.6 0.2 0.8 

<14 13.3 11.3 27.7 2.5 2.0 5.3 

<16 25.7 22.5 49.4 5.9 5.6 15.8 

<18 43.9 33.9 67.5 15.9 9.5 30.0 

<19 52.3 40.7 73.2 21.7 14.3 38.6 

<20 55.8 43.0 75.7 24.0 15.5 41.6 

<25 66.1 51.4 80.3 33.7 21.8 49.2 

<30 68.3 55.8 81.4 37.0 25.7 51.0 

<39 69.3 57.4 82.0 38.1 26.7 51.4 

Mean age	 NA NA NA NA NA NA 

*N = 3,536 

†

N = 5,143
 

NA = data not available.
 

adolescent becoming a cigarette smoker (USDHHS 

1994). In a study conducted in Los Angeles and San 

Diego in 1986, African American parents placed a 

higher value than white parents on becoming involved 

in preventing their children from beginning to smoke 

(Flay et al. 1988; Koepke et al. 1990). Data from two 

surveys conducted in eight U.S. communities in 1988 

and 1989 indicate that African American adults were 

more likely than white adults to perceive cigarette 

smoking as a very serious health problem in their community, to favor eliminating vending machines from 

places where teenagers gather, and to prohibit smoking in their car (Royce et al. 1993). 

More recent findings from focus groups conducted at several U.S. sites suggest that African American parents may be more likely than white parents to 

express clear antismoking messages (McIntosh 1995; 

Mermelstein et al. 1996). Findings from these focus 

40 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Men who had ever smoked daily 

First tried a cigarette Began smoking daily 

African 

American Hispanic White 

African 

American Hispanic White 

8.9 

22.7 

45.7 

73.7 

81.1 

87.0 

96.1 

99.9 

100.0 

15.9 

13.6 

29.7 

55.4 

74.1 

83.4 

86.9 

97.0 

99.6 

100.0 

15.3 

15.7 

36.7 

61.0 

83.9 

90.5 

93.0 

98.4 

98.9 

100.0 

14.6 

3.0 

8.3 

24.2 

45.0 

56.4 

63.5 

89.7 

98.9 

100.0 

18.4 

3.2 

10.6 

25.7 

45.1 

60.7 

65.4 

85.7 

97.9 

100.0 

18.6 

Women who had ever smoked daily 

2.7 

9.2 

23.7 

52.9 

68.8 

77.1 

95.1 

97.7 

100.0 

17.6 

First tried a cigarette Began smoking daily 

African 

American Hispanic White 

African 

American Hispanic White 

5.9 

20.1 

38.6 

66.8 

77.2 

81.4 

96.0 

99.6 

100.0 

16.6 

6.9 

25.4 

48.7 

68.6 

78.2 

80.8 

94.5 

99.2 

100.0 

16.2 

8.9 

37.8 

66.1 

85.9 

92.0 

94.4 

99.2 

99.9 

100.0 

14.6 

1.6 

6.7 

15.5 

41.8 

57.0 

62.9 

88.4 

97.2 

100.0 

18.9 

0.7 

7.6 

21.1 

35.4 

53.4 

58.0 

81.8 

96.4 

100.0 

19.5 

1.6 

10.3 

30.7 

58.3 

75.0 

80.8 

95.6 

99.2 

100.0 

17.1 

Source: Substance Abuse and Mental Health Services Administration, public use 

data tapes, 1994–1995. 

groups also suggest that smoking by African American adolescents may be a sign of disrespect toward 

parents (USDHHS 1994). Additionally, African American adolescent females appear to perceive that abstinence from smoking enhances their image, whereas 

white girls are more likely to perceive that smoking 

empowers them (perhaps because of themes expressed 

in cigarette advertising) (Mermelstein et al. 1996). The 

responses of African American community leaders, 

including that of former USDHHS Secretary Louis 

Sullivan, against cigarette marketing campaigns that 

appear to target African Americans may have influenced young people’s attitudes and behaviors about 

smoking (McIntosh 1995). 

Further research is needed to better understand the large decreases in smoking prevalence 

that occurred among African American youth in 

the 1970s and 1980s. Research is also needed to better 

Patterns of Tobacco Use 41 
42 Chapter 2 

Surgeon General's Report 

Table 12.	 Percentage of African American and white high school seniors who reported previous-month and 

heavy* smoking, by selected variables, Monitoring the Future surveys, United States, 1976–1994 

Previous-month smoking (%) 

1976–1979 1980–1984 1985–1989 1990–1994 

Characteristic 

African 

Americans Whites 

African 

Americans Whites 

African 

Americans Whites 

African 

Americans Whites 

Parental education 

Less than high school 34.0 42.0 23.2 36.8 13.9 37.6 11.8 37.6 

High school 35.3 39.5 21.2 34.1 14.1 34.8 10.7 34.8 

Some college 30.9 35.0 20.7 29.2 16.0 31.3 9.4 32.5 

College 29.4 32.4 18.3 26.7 13.3 29.1 9.3 32.4 

Some postgraduate 30.1 31.2 21.9 23.7 14.7 28.3 9.8 31.7 

study 

Personal income† 

Low NA NA 16.4 24.5 12.6 24.6 7.5 24.6 

Medium NA NA 19.4 30.5 14.9 28.8 9.4 29.7 

High NA NA 22.8 33.3 14.1 34.5 9.8 35.5 

Very high NA NA 23.4 37.8 16.5 39.8 12.4 41.3 

School performance 

Far above average 25.9 25.8 16.2 21.0 11.4 23.0 8.0 24.6 

Slightly above average 31.2 35.8 20.2 29.6 12.7 30.7 8.4 32.2 

Average 34.4 45.3 22.5 38.5 15.3 38.9 10.6 39.4 

Below average 40.0 52.4 28.0 44.1 20.5 46.7 17.6 48.3 

Importance of religion 

Very important 29.3 25.0 19.1 21.9 11.4 21.9 8.2 22.1 

Important 34.1 38.9 23.4 32.4 16.7 32.0 11.5 33.7 

Not/somewhat 40.0 43.0 23.5 35.2 18.3 36.8 12.4 38.5 

important 

Region 

Northeast 37.1 40.4 25.7 33.5 18.1 34.9 10.9 34.9 

North Central 34.8 38.9 20.3 32.8 16.0 34.6 10.1 35.5 

South 32.6 37.7 20.6 31.7 12.7 31.1 10.1 33.6 

West 29.1 25.8 20.2 21.3 17.8 26.0 8.0 26.6 

Locale in which respondent 

grew up 

Farm 33.6 37.9 24.9 31.6 26.7 33.0 22.3 31.9 

Country 35.5 38.3 23.3 30.7 14.6 33.1 12.2 32.2 

Small city 28.5 37.4 20.0 30.1 14.1 31.1 12.1 32.6 

Medium-sized city 31.5 37.4 20.1 31.2 14.5 32.3 8.7 34.7 

Suburb of medium- 34.5 36.9 18.5 32.0 16.5 32.0 6.8 34.7 

sized city 

Large or very large city 36.2 38.5 22.3 32.0 13.9 33.4 8.5 33.6 

Suburb of large or 34.1 32.7 20.0 29.1 14.0 30.2 9.0 33.8 

very large city 

*Heavy cigarette smoking is 10 or more cigarettes smoked per day reported at time of survey. †

Personal income is the sum of income from employment, allowance, and other sources. Trend data are available
 

for 1982–1994 only.
 

NA = data not available.
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Heavy cigarette smoking (%) 

1976–1979 1980–1984 1985–1989 1990–1994 

African 

Americans 

African 

Americans 

African 

Americans 

African 

Whites Whites Whites Americans Whites 

9.3 24.0 6.2 21.5 3.0 21.3 2.7 19.1 

10.8 21.6 4.6 17.4 2.4 15.7 1.6 15.9 

9.1 17.4 4.8 13.1 3.3 12.3 1.4 12.6 

7.2 14.9 3.5 10.3 2.4 9.5 1.6 11.6 

9.1 14.8 5.3 9.0 4.1 8.3 1.2 9.8 

NA NA 3.1 10.1 2.2 8.7 1.1 8.0 

NA NA 3.4 12.5 3.0 9.2 1.7 9.1 

NA NA 6.1 16.3 2.4 14.2 1.2 13.5 

NA NA 6.9 20.7 3.3 19.8 2.3 20.1 

7.6 10.6 3.7 8.1 3.0 7.1 1.5 7.1 

8.4 17.7 4.1 12.8 2.0 11.2 1.2 11.3 

10.2 25.9 5.2 20.2 2.7 17.5 1.5 17.3 

11.7 33.5 7.2 26.1 5.1 25.4 4.4 26.0 

8.5 10.4 4.0 8.7 2.1 7.3 1.2 7.5 

9.4 19.1 5.7 14.5 3.1 12.0 1.9 11.9 

12.8 25.0 6.0 18.6 3.9 16.3 2.4 16.5 

12.2 23.2 6.3 17.4 4.7 16.6 2.1 14.4 

11.1 19.3 5.3 16.0 3.0 13.8 1.9 13.9 

9.2 19.5 4.7 14.8 2.1 12.4 1.6 13.8 

7.4 12.5 4.2 7.9 3.3 8.4 1.1 8.8 

9.9 16.4 5.4 12.3 8.1 12.2 5.1 12.2 

10.0 20.2 5.1 14.9 2.9 13.7 1.5 13.1 

8.7 19.0 4.5 13.7 2.7 12.2 2.8 12.5 

9.4 20.2 4.9 15.4 2.2 13.1 1.3 13.4 

9.0 20.6 4.0 15.2 2.8 12.6 1.1 12.7 

10.8 22.9 5.4 16.5 2.3 14.9 1.2 14.0 

9.3 16.4 3.8 14.0 3.7 11.0 1.2 12.2 

Source: Institute for Social Research, University of Michigan, public use data tapes, 1976–1994. 

Patterns of Tobacco Use 43 
 

Surgeon General's Report 

understand the reasons for the increase in prevalence 

that occurred in the early 1990s (Figures 2 and 3) (CDC 

1996). 

Other risk behaviors. The Surgeon General’s report Preventing Tobacco Use Among Young People 

(USDHHS 1994) has concluded that “Tobacco use 

in adolescence is associated with a range of healthcompromising behaviors, including being involved in 

fights, carrying weapons, engaging in higher-risk 

sexual behavior, and using alcohol and other drugs” 

(p. 9). Escobedo and colleagues (1997) have observed 

these associations for African American adolescent 

males and females. Using data from the YRBS supplement of the 1992 NHIS, the researchers found that after their analysis controlled statistically for age, 

ethnicity, sex, parental educational level, region of the 

country, and other risk behaviors, marijuana use, binge 

drinking, and physical fighting were significantly associated with cigarette smoking among African American adolescent males and females. Focus group data 

suggest that African American youths are more likely 

than white youths to pair cigarette smoking with marijuana use as a way to maintain and enhance the drug 

effects of each (Mermelstein et al. 1996). 

Smokeless Tobacco Use 

The prevalence of smokeless tobacco use among 

African American adolescents has remained fairly 

constant in recent years. According to the MTF surveys, previous-month smokeless tobacco use (based 

on two-year rolling averages) was reported by 1.8 

percent of eighth-grade African American students in 

1992 and 2.2 percent in 1996; among tenth-grade 

students, the prevalence was 2.9 percent in 1992 and 

2.5 percent in 1996; and among high school seniors, 

the prevalence was 2.1 percent in 1987 and 2.7 percent in 1996 (Johnston et al. 1996; Institute for Social 

Research, University of Michigan, unpublished data 

from the 1996 MTF surveys). Similarly, the YRBS data 

indicate that 2.1 percent of African American high 

school students were current smokeless tobacco users in 1991 (USDHHS 1994), and 2.2 percent were so 

in 1995 (CDC 1996). 

African American adolescent males are substantially less likely than white adolescent males to use 

smokeless tobacco. Among male high school students 

participating in the 1995 YRBS, for example, 3.5 percent 

of African Americans and 25.1 percent of whites reported 

that they had used smokeless tobacco in the previous 

month (CDC 1996). Among females, 1.1 percent of African Americans and 2.5 percent of whites reported they 

had used smokeless tobacco in the previous month. 

American Indians and Alaska Natives 

Data assessing long-term trends in tobacco use 

among American Indians and Alaska Natives have 

been unavailable, for the most part, because national 

surveys and databases have only recently begun to 

identify persons of American Indian or Alaska Native 

ancestry. Studies using data from regional surveys or 

data on specific American Indian tribes have, however, 

provided useful information about tobacco use among 

members of these groups. Because the geographic 

location of American Indian and Alaska Native people 

reflects unique cultural and historical experiences, 

researchers should consider these differences when 

interpreting region-specific data about smoking prevalence. Data from regional studies also may provide 

information that is useful in developing culturally 

appropriate tobacco control efforts. 

National surveys provide limited capability to 

assess the level of tobacco use and the effectiveness of 

tobacco control efforts among American Indians and 

Alaska Natives. The NHIS, for example, did not begin identifying American Indian and Alaska Native 

respondents until 1978. Because American Indians and 

Alaska Natives make up a small proportion of the U.S. 

population, data must be aggregated from several 

years to provide meaningful estimates. 

Also noteworthy is that the data on tobacco use 

among American Indians and Alaska Natives include 

some ceremonial use (e.g., in pipes) in addition to daily 

addictive behavior (see Chapter 4). Anecdotal information also suggests that standard definitions and 

classifications of smoking may not accurately reflect 

smoking habits among American Indians, some of 

whom may smoke no more than one or two cigarettes 

per day (Nathaniel Cobb, personal communication, 

1994; Roscoe et al. 1995). Yet American Indians who 

smoke a few cigarettes every day are classified in the 

<15-cigarettes-per-day category, which may imply a 

higher overall consumption than actually exists. Such 

differences in amounts of daily smoking may have 

important implications for the design of culturally appropriate smoking cessation interventions targeting 

American Indians. 

Prevalence of Cigarette Smoking 

Among American Indian and Alaska Native men 

and women, rates of smoking have been substantially 

higher than smoking rates in any other U.S. subgroup. 

In the 1987 Survey of American Indians and Alaska 

Natives (SAIAN) of the National Medical Expenditure 

Survey, 32.8 percent of respondents reported being 

44 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

current smokers (Lefkowitz and Underwood 1991). 

This survey—the only nationally representative 

sample designed to assess the health practices of 

people of American Indian and Alaska Native ancestry—targets people who live on or near reservations 

and who are eligible for services provided by the Indian Health Service (IHS). The NHIS rate of smoking 

among American Indians and Alaska Natives for 1987 

and 1988 (39.2 percent) was greater than the SAIAN 

estimate, perhaps because of different modes of 

administration and sampling (tribally enrolled beneficiaries in the SAIAN and the general population of 

American Indians and Alaska Natives in the NHIS). 

In a more recent survey—conducted on reservations between 1989 and 1992 and involving 4,549 American Indians 45–74 years old in 13 tribes in Arizona, North 

Dakota, South Dakota, and southeastern Oklahoma—the 

prevalence of cigarette smoking was higher in nearly all 

American Indian groups (40.5 percent for men and 29.3 

percent for women) than in the general U.S. population, 

but wide variation was notable (Welty et al. 1995). In 

this study, known as the Strong Heart Study, the smoking prevalence was highest in North Dakota and South 

Dakota (53.1 percent for men and 45.3 percent for women) 

and lowest in Arizona (29.7 percent for men and 12.9 

percent for women). 

According to the NHIS data, the overall prevalence of cigarette smoking among American Indians 

and Alaska Natives was 48.2 percent in 1978–1980 and 

39.2 percent in 1994–1995. Although the data are imprecise, they suggest a substantial drop in prevalence 

for men from 1978–1980 to 1983–1985 (Table 13) 

(NCHS, public use data tapes, 1978–1995). However, 

no progress for men was observed from 1983–1985 to 

1994–1995 and, for women, no progress was observed 

from 1978–1980 to 1994–1995. 

Another major source of data on smoking patterns among American Indians and Alaska Natives is the 

BRFSS, which, for these analyses, included data collected 

in 47 states and the District of Columbia (CDC 1992a). 

The BRFSS data for 1987–1991 show that among American Indians and Alaska Natives, 33.4 percent of men and 

26.6 percent of women reported that they were current 

smokers. The 95 percent confidence intervals associated 

with smoking rates overlap between American Indian 

and Alaska Native women and men in both surveys. 

Even though data were aggregated for several years, the 

small sample sizes of American Indians and Alaska Natives in both surveys produced imprecise estimates that 

make it impossible to determine whether the prevalence 

of smoking actually differed between men and women. 

percent in 1987–1988 and 37.2 percent in 1990–1991) 

differed substantially from the prevalence found in the 

1987–1991 BRFSS (26.6 percent). Similarly, the prevalence of smoking among American Indian and Alaska 

Native men in the NHIS (43.5 percent in 1987–1988 and 

32.9 percent in 1990–1991) differed appreciably from 

the prevalence found for men in the 1987–1991 BRFSS 

(33.4 percent). Methodological differences between the 

surveys may explain these differences. Household, 

face-to-face interviews were conducted for the NHIS, 

whereas telephone interviews were performed for the 

BRFSS (Goldberg et al. 1991; Sugarman et al. 1992; 

Leonard et al. 1993). Because telephone coverage in 

the areas where American Indians and Alaska Natives 

live tends to be lower than in areas where other ethnic 

groups live (Goldberg et al. 1991; Sugarman et al. 1992), 

sometimes as low as 60.4 percent of households (U.S. 

Bureau of the Census 1994), American Indians and 

Alaska Natives probably were less likely than others 

to have been included in the BRFSS surveys. Moreover, because telephone service requires financial ability to pay, persons of higher socioeconomic status may 

have been more likely than other persons to be included in the BRFSS surveys (Thornberry and Massey 

1988). Thus, the BRFSS may have yielded lower smoking rates than the NHIS because the BRFSS surveys 

selected more affluent respondents, who were less 

likely than others to smoke. 

The prevalence of smoking among American 

Indian and Alaska Native women in the NHIS (35.2 

Estimated rates and trends in cigarette smoking 

were not significantly related to educational attainment, according to NHIS (Table 13) and SAIAN data. 

However, both surveys suffered from imprecision because of small sample sizes. 

Number of Cigarettes Smoked Daily 

NHIS data for 1978–1995 show few variations 

over time in the number of cigarettes smoked per day 

among American Indian and Alaska Native smokers 

(Table 14) (NCHS, public use data tapes, 1978–1995). 

In the years 1978–1980, 39.9 percent of American Indian and Alaska Native smokers reported smoking 

fewer than 15 cigarettes per day, and 25.2 percent reported smoking 25 or more cigarettes per day. By 1994– 

1995, the proportion of American Indian and Alaska 

Native smokers who smoked fewer than 15 cigarettes 

per day was 49.9 percent, whereas the proportion who 

smoked 25 or more cigarettes per day was 17.0 percent. Data from the Strong Heart Study showed that 

American Indian smokers reported smoking fewer 

cigarettes per day (range of 6.1 among women in Arizona to 15.0 among men in North Dakota and South 

Dakota) than the national average (Welty et al. 1995). 

Patterns of Tobacco Use 45 
 

Surgeon General's Report 

Table 13.	 Percentage of American Indian and Alaska Native adults who reported being current cigarette 

smokers,* overall and by gender, age, and education, National Health Interview Surveys, United 

States, 1978–1995 aggregate data 

1978–1980† 

–––––––––– 

% ±CI‡

1983–1985† 

–––––––––– 

 % ±CI

1987–1988† 

–––––––––– 

 % ±CI

1990–1991† 

–––––––––– 

 % ±CI 

1992–1993† 

–––––––––– 

% ±CI 

1994–1995† 

–––––––––– 

Characteristic % ±CI 

Total 48.2 5.8 35.6 8.0 39.2 5.9 35.0 6.9 39.1 5.1 39.2 7.3 

Gender 

Men 63.0 11.0 41.4 12.9 43.5 9.3 32.9 7.1 37.5 9.3 45.4 13.1 

Women 34.1 10.1 32.3 8.8 35.2 6.2 37.2 9.1 40.3 8.6 34.2 8.7 

Age (years) 

18–34 53.3 9.2 39.9 13.6 38.1 7.1 36.1 9.3 41.3 8.7 48.0 11.1 

35–54 53.5 11.0 36.7 12.1 47.4 8.0 40.2 7.0 45.1 8.4 42.9 11.3 

>55 33.4 15.1 24.7 11.3 29.2 10.7 23.4 14.9 22.3 9.3 10.5 8.9 

Education§ 

Less than high school 49.9 8.8 28.7 11.3 42.5 8.3 33.4 8.9 42.6 12.3 44.1 14.2 

High school graduate/ 

 any college 

35.0 11.5 36.7 10.2 35.7 6.7 35.4 7.9 37.9 7.4 33.5 7.8

*Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978–1991, 

current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked. For 1992–1995, current smokers include persons 

who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they 

currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

In the years 1978–1980, American Indian and Alaska 

Native men were more likely than women to smoke 

25 or more cigarettes per day (Table 14). Since 1980, 

however, the proportion of men smoking 25 or more 

cigarettes per day has declined. 

Cigarette consumption data from the BRFSS and 

the NHIS cannot be compared directly because the 

BRFSS data are for the mean number of cigarettes 

smoked daily (CDC 1992a). However, both sources of 

data indicate that the number of cigarettes smoked is 

slightly greater among older than among younger 

American Indians and Alaska Natives. 

Quitting Behavior 

State and regional surveys also indicate that the 

prevalence of smoking cessation remains relatively low 

among American Indian and Alaska Native smokers 

compared with smokers in other racial/ethnic groups 

(Goldberg et al. 1991; Lando et al. 1992). In the past 17 

years, the percentage of American Indians and Alaska 

Natives who have ever smoked 100 cigarettes and have 

quit smoking has changed only slightly overall; NHIS 

data indicate that the prevalence of cessation was 31.6 

percent in 1978–1980 and 32.9 percent in 1994–1995 

(Table 15) (NCHS, public use data tapes, 1978–1993). 

During this period, the prevalence of smoking cessation fluctuated substantially for both genders, with 

similar estimates reported for 1978–1980 and 1994– 

1995. The prevalence of smoking cessation among 

American Indians and Alaska Natives has increased 

with increasing age: those aged 18–34 years have had 

the lowest prevalence of cessation, those aged 35–54 

years have had intermediate proportions, and those 

aged 55 years and older have had the highest prevalence of cessation. The prevalence of cessation increased among older American Indians and Alaska 

Natives; however, no progress occurred among those 

46 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 14.	 Percentage of adult American Indian and Alaska Native smokers* who reported smoking <15, 

15–24, or >25 cigarettes per day, overall and by gender, age, and education, National Health 

Interview Surveys, United States, 1978–1995 aggregate data 

1978–1980† 

–––––––––– 

% ±CI‡

1983–1985† 

–––––––––– 

 % ±CI

1987–1988† 

–––––––––– 

 % ±CI

1990–1991† 

–––––––––– 

 % ±CI 

1992–1993† 

–––––––––– 

% ±CI 

1994–1995† 

–––––––––– 

Characteristic % ±CI 

Total

 <15 cigarettes 39.9 10.2 38.2 12.5 33.7 7.5 46.3 7.3 50.0 11.9 49.9 14.6 

15–24 cigarettes 34.9 9.5 48.5 12.5 45.8 7.6 34.7 8.2 32.6 9.3 33.0 12.7 

>25 cigarettes 25.2 9.2 13.3 9.6 20.6 5.3 19.1 6.7 17.4 8.8 17.0 8.3 

Gender 

Men

 <15 cigarettes 35.8 12.7 22.7 15.2 20.9 10.4 35.5 10.2 38.7 15.9 36.2 28.1 

15–24 cigarettes 31.8 12.7 63.6 17.8 53.8 11.6 44.9 14.9 39.8 15.6 42.1 23.1 

>25 cigarettes 32.3 14.8 13.7 12.1 25.4 8.7 19.7 10.6 21.5 12.0 21.7 15.7 

Women

 <15 cigarettes 47.1 16.9 48.9 14.6 48.3 11.2 56.2 9.5 58.9 14.7 64.9 12.3 

15–24 cigarettes 40.3 17.4 38.1 12.7 36.6 12.2 25.3 7.3 27.0 11.0 23.1 11.2 

>25 cigarettes 12.7 11.2 13.0 12.2 15.1 5.6 18.5 7.8 14.1 11.8 12.0 6.4 

Age (years) 

18–34

 <15 cigarettes 42.0 15.7 45.0 18.7 51.8 15.1 59.5 12.7 49.9 16.7 57.6 18.9 

15–24 cigarettes 41.0 11.7 49.1 18.1 40.8 13.3 29.7 11.7 35.0 14.3 29.7 17.0 

>25 cigarettes 17.0 11.2 5.9 7.1 7.4 5.7 10.8 5.3 15.1 14.4 12.6 10.4 

35–54

 <15 cigarettes 26.9 15.7 26.6 17.2 21.3 9.9 37.3 10.2 46.1 19.1 43.3 17.2 

15–24 cigarettes 34.3 15.2 52.1 21.2 40.4 12.9 39.6 10.8 31.1 15.7 32.3 16.1 

>25 cigarettes 38.8 19.5 21.3 19.1 38.3 14.9 23.2 10.9 22.9 12.4 24.3 14.6 

>55

 <15 cigarettes 60.5 23.6 41.3 29.4 20.9 19.3 30.8 12.9 66.1 24.3 14.6 22.4 

15–24 cigarettes 19.7 19.6 38.3 31.2 70.0 22.8 35.7 22.9 29.4 24.0 75.5 30.2 

>25 cigarettes 19.8 19.9 20.4 33.3 9.2 9.8 33.5 30.2 4.4 6.3 9.9 19.8 

Education§ 

Less than high school

 <15 cigarettes 38.0 13.7 30.2 18.1 19.8 12.7 33.2 14.8 45.0 23.9 37.4 21.7 

15–24 cigarettes 38.6 13.9 52.7 20.6 51.1 14.1 39.4 18.6 30.9 17.5 40.1 21.1 

>25 cigarettes 23.4 13.1 17.1 20.3 29.1 10.5 27.4 14.1 24.1 22.0 22.5 17.2 

High school/any college

 <15 cigarettes 37.8 17.7 36.9 16.4 31.3 11.6 45.6 9.1 47.5 13.5 57.0 16.3 

15–24 cigarettes 27.8 18.9 48.5 17.4 47.9 11.7 33.4 9.7 33.7 12.2 25.8 13.4 

>25 cigarettes 34.4 19.1 14.6 13.4 20.8 8.8 21.0 8.7 18.8 9.7 17.2 11.9 

*

Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978–1991, 

current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked. For 1992–1995, current smokers include persons 

who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they 

currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

Patterns of Tobacco Use 47 
 

Surgeon General's Report 

Table 15.	 Percentage of adult American Indian and Alaska Native ever smokers who have quit,* overall and 

by gender, age, and education, National Health Interview Surveys, United States, 1978–1995 

aggregate data 

1978–1980† 

–––––––––– 

% ±CI‡

1983–1985† 

–––––––––– 

 % ±CI

1987–1988† 

–––––––––– 

 % ±CI

1990–1991† 

–––––––––– 

 % ±CI 

1992–1993† 

–––––––––– 

% ±CI 

1994–1995† 

–––––––––– 

Characteristic % ±CI 

Total 31.6 7.9 37.7 9.3 36.1 7.5 38.2 8.2 34.6 9.1 32.9 9.6 

Gender 

Men 28.5 11.8 38.2 12.9 37.5 9.5 44.0 9.7 43.8 15.3 28.3 13.9 

Women 36.5 11.8 37.4 12.8 34.3 8.4 31.7 9.8 25.2 7.7 37.2 13.0 

Age (years) 

18–34 29.5 12.0 30.2 15.1 28.0 8.2 28.3 10.1 20.7 13.4 16.3 13.3 

35–54 25.4 12.1 38.0 15.2 34.7 9.5 33.0 8.6 34.8 10.5 29.1 13.4 

>55 44.8 18.4 54.1 17.5 50.9 17.3 63.5 19.5 61.7 15.4 81.7 14.8 

Education§ 

Less than high school 28.4 11.3 43.8 15.7 29.8 12.4 49.4 11.7 37.4 13.1 39.3 15.1 

High school/any college 47.3 15.6 39.1 13.3 43.1 9.1 36.0 10.3 36.2 12.3 36.5 11.0 

*Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. The prevalence 

of cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who 

reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were 

not smoking, and ever smokers include current and former smokers.

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

aged 18–54 years. Interviews with patients at urban 

IHS clinics in Milwaukee, Minneapolis, Seattle, and 

Spokane also showed a low prevalence of cessation 

(29.7 percent) (Lando et al. 1992), compared with 45 

percent reported for the total U.S. population during 

the same time. 

Data from the NCI Supplement of the 1992–1993 

CPS indicate that among American Indians and Alaska 

Natives aged 18 years and older who were daily smokers one year before being surveyed, 62.8 percent reported that they were still smoking daily and that they 

had not tried quitting for at least one day during the 

previous year (Table 4). Another 28.9 percent had tried 

quitting for at least one day, 3.7 percent were occasional 

smokers (i.e., smoked only on some days), 1.8 percent 

had not smoked for the past 1–90 days, and 2.8 percent had not smoked for the past 91–364 days. This 

distribution was similar to that among whites. 

Women of Reproductive Age 

Since 1978, rates of smoking have remained strikingly high among American Indian and Alaska 

Native women of reproductive age (18–44 years) participating in the NHIS (Table 16) (NCHS, public use 

data tapes, 1978–1995). Between 1978 and 1995, the 

prevalence of cigarette smoking among reproductiveaged American Indian and Alaska Native women 

changed little overall, and the data are not precise 

enough to allow meaningful comparisons according 

to educational attainment. 

A recent study by Davis and colleagues (1992) 

confirms that the prevalence of smoking is higher 

among American Indian women of reproductive 

age than among their counterparts in other racial/ 

ethnic groups. The investigators analyzed birth certificates issued in Washington state between January 1, 

48 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 16.	 Percentage of American Indian and Alaska Native women of reproductive age who reported 

being current cigarette smokers,* overall and by education, National Health Interview Surveys, 

United States, 1978–1995 aggregate data 

1978–1980† 

–––––––––– 

% ±CI‡

1983–1985† 

–––––––––– 

 % ±CI

1987–1988† 

–––––––––– 

 % ±CI

1990–1991† 

–––––––––– 

 % ±CI 

1992–1993† 

–––––––––– 

% ±CI 

1994–1995† 

–––––––––– 

Characteristic % ±CI 

Total 40.2 12.8 35.9 11.3 39.2 8.9 43.3 11.1 39.7 9.4 44.3 12.0 

Education§ 

Less than high school 60.4 23.7 47.6 24.9 53.1 18.9 61.3 14.5 82.1 18.6 62.4 30.0 

High school/any college 17.2 13.1 27.6 11.7 30.5 9.3 42.9 14.4 32.7 11.2 45.6 14.4 

*

Excludes American Indians and Alaska Natives who indicated they were of Hispanic origin. For 1978–1991, 

current cigarette smokers include women aged 18–44 years who reported smoking at least 100 cigarettes in 

their lives and who reported at the time of survey that they currently smoked. For 1992–1995, current smokers 

include women aged 18–44 years who reported smoking at least 100 cigarettes in their lives and who reported 

at the time of survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data 

were combined. 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

1984, and December 31, 1988, and found that the prevalence of smoking among American Indian mothers, adjusted for maternal age and marital status, was 1.3 times 

higher than the prevalence among white mothers. 

Data from the 1988 NMIHS indicate that 35 percent of American Indian mothers sampled reported 

smoking cigarettes in the 12 months before delivery 

(Sugarman et al. 1994). Recent birth certificate data 

from U.S. final natality statistics show that 20.9 percent of American Indian and Alaska Native mothers 

smoked during pregnancy (Ventura et al. 1997), a slight 

decline from 23.0 percent in 1989 (Table 6). The prevalence of smoking among American Indian mothers was 

higher than all groups in 1989–1995 (Table 6). 

Young People 

Cigarette Smoking 

One of the few studies focusing on tobacco use 

among American Indian and Alaska Native youths is 

the MTF, which includes a series of surveys of high 

school seniors. Between 1976 and 1994, American Indian and Alaska Native high school seniors had higher 

rates of cigarette smoking than all of their counterparts, 

although the rate of decline was more rapid than for 

whites (Table 7). The prevalence of previous-month 

cigarette smoking during 1990–1994 was 39.4 percent 

among American Indian and Alaska Native females 

and 41.1 percent among males. During 1985–1989, 

rates of daily smoking and of smoking one-half pack 

or more per day were higher among American Indian 

and Alaska Native youths than among youths of other 

racial/ethnic groups (Bachman et al. 1991a). 

Data from a revised version of the Adolescent 

Health Survey showed that for every grade level after 

the seventh, American Indian and Alaska Native females were somewhat more likely to be daily cigarette 

smokers than were American Indian males. The prevalence of daily cigarette smoking among females increased from 8.9 percent in junior high school to 17.8 

percent in high school, whereas among males the 

prevalence of daily cigarette smoking increased from 

8.1 percent in junior high school to 15.0 percent in high 

school (Blum et al. 1992). 

Smokeless Tobacco Use 

The use of smokeless tobacco is also high among 

American Indian and Alaska Native youths. Bruerd 

(1990) reviewed nine studies of schoolchildren’s 

use of smokeless tobacco in South Dakota, Montana, 

Patterns of Tobacco Use 49 
50 Chapter 2 

Surgeon General's Report 

Nebraska, Washington, Arizona, New Mexico, and 

Alaska and found that the prevalence of regular 

smokeless tobacco use ranged from 18 percent among 

students in kindergarten through the sixth grade to 

55.9 percent among students in the ninth and tenth 

grades. The percentage of schoolchildren who reported ever using or experimenting with smokeless 

tobacco ranged from 29 to 82 percent. In general, the 

findings suggested a young age at onset of smokeless 

tobacco use, similar prevalence of use among adolescent boys and girls, and higher overall prevalence of 

use among American Indian and Alaska Native schoolchildren than among students in other populations. A 

1987–1988 survey of 650 American Indian and Alaska 

Native youths at three IHS sites (Alaska; the Billings 

region, which encompasses Montana and Wyoming; 

and the Navajo region, which encompasses portions 

of Arizona, Colorado, New Mexico, and Utah) indicated that these youths were experimenting with and 

regularly using smokeless tobacco at higher rates than 

white youths (Backinger et al. 1993). 

Regional and Tribal Tobacco Use 

Cigarette Smoking 

Although a high rate of smoking has been estimated nationally for American Indians and Alaska 

Natives, regional and state differences in tobacco-use 

patterns are evident when 1988–1992 aggregate data 

from the BRFSS are considered. High smoking 

prevalences were found in Alaska (45.1 percent), the 

Northern Plains (Montana, Nebraska, North Dakota, 

and South Dakota) (44.2 percent), and the Northern 

Woodlands (Iowa, Michigan, Minnesota, and Wisconsin) (35.6 percent), whereas much lower overall smoking prevalences were found in California (25.4 percent) 

and the Southwest (Arizona, Colorado, New Mexico, 

and Utah) (17.0 percent) (Table 17) (CDC, public use 

data tapes, 1988–1992). The prevalence of current cigarette smoking varied by geographic region more than 

twofold for men and nearly threefold for women. For 

example, 21.3 percent of men and 13.5 percent of 

women in the Southwest reported that they currently 

Table 17.	 Percentage of American Indian and Alaska Native adults who reported being current cigarette 

smokers,* overall and by region/state, gender, age, and education, Behavioral Risk Factor 

Surveillance System, 1988–1992 aggregate data 

Northern 

 Plains†

 % ±CI

Northern 

 Woodlands† 

 % ±CI 

Alaska 

 % ±CI‡

California

Characteristic % ±CI

Total 45.1 5.9 25.4 7.0 44.2 7.8 35.6 4.8 

Gender 

Men 48.4 8.7 27.9 10.5 49.1 11.3 33.0 7.6 

Women 41.7 8.0 22.7 8.9 38.4 9.9 37.6 6.2 

Age (years) 

18–34 48.5 9.0 20.9 8.7 51.2 12.4 33.4 6.7 

35–54 41.5 8.6 34.4 13.4 47.2 12.4 45.4 9.0 

>55 41.3 14.6 24.0 20.6 27.3 15.1 27.0 9.1 

Education§ 

Less than high school 43.1 11.2 25.8 15.3 44.5 14.8 40.6 11.0 

High school/any college 44.9 7.3 32.5 9.7 40.1 9.8 35.3 5.7 

*Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in 

their lives and who reported at the time of survey that they currently smoked.

†

The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern 

Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes 

Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; 

and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor 

Surveillance System during this period. 
Patterns of Tobacco Use 51 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

smoked, compared with 49.1 percent of men and 38.4 

percent of women in the Northern Plains (Table 17). 

The majority of American Indians and Alaska 

Natives (83.3 percent) responding to the BRFSS 

smoked 15 or fewer cigarettes per day; this finding was 

consistent across all states and regions (Table 18) (CDC, 

public use data tapes, 1988–1992). Overall, female 

American Indians and Alaska Natives smoked fewer 

cigarettes than their male counterparts—a finding 

that was consistent across all states and regions. 

American Indian smokers in the Northern Plains (13.5 

percent) were the most likely to smoke 25 or more cigarettes per day. American Indian smokers in the Southwest (51.2 percent) and the Pacific Northwest (46.8 

percent) had the highest prevalence of cessation, 

whereas American Indians in the Northern Plains (31.8 

percent) and Alaska Natives (37.0 percent) had the lowest prevalence of cessation (Table 19) (CDC, public use 

data tapes, 1988–1992). 

In similar analyses of the BRFSS data aggregated for 1985–1988, the prevalence of smoking 

varied markedly by gender and geographic region 

(Sugarman et al. 1992). For American Indian men, the 

prevalence of smoking was highest among those living in the Plains region (Iowa, Minnesota, Montana, 

Nebraska, North Dakota, South Dakota, and Wisconsin) (48.4 percent), followed by those in the West Coast 

region (California, Idaho, and Washington) (25.2 percent) and the Southwest (Arizona, New Mexico, and 

Utah) (18.1 percent). Similarly, for American Indian 

women, the prevalence of smoking was highest among 

those living in the Plains region (57.3 percent), followed 

by those in the West Coast region (31.6 percent) and 

the Southwest (14.7 percent). 

Regional and tribal data on cigarette smoking are 

also available from a probability sample of American 

Indians living on or near the northern Montana 

Blackfeet Reservation and those served by the Native 

American Center in Great Falls, Montana, in 1987 

(Goldberg et al. 1991). Among Blackfeet Indians, 34 

percent of men and 50 percent of women reported that 

they smoked cigarettes. Among American Indians in 

Pacific 

Northwest† 

% ±CI

Oklahoma 

 % ±CI 

Southwest†

 % ±CI

 Other†

 % ±CI

 Total

 % ±CI 

30.4 7.3 33.1 6.0 17.0 4.6 28.9 4.2 29.2 2.5 

36.2 12.7 35.4 9.2 21.3 8.2 36.5 6.4 34.4 4.0 

26.0 8.9 31.2 7.9 13.5 5.0 21.3 5.2 24.2 3.1 

33.5 12.6 37.6 9.6 13.3 5.6 30.2 6.8 28.9 3.8 

35.0 12.8 30.3 8.4 18.9 8.8 33.6 7.1 33.8 4.4 

21.7 10.6 26.2 14.7 29.8 14.2 18.6 6.6 22.5 5.3 

25.1 14.4 42.5 15.4 29.7 12.3 34.0 9.4 33.4 5.6 

31.2 8.7 33.9 7.3 15.1 5.9 29.4 5.0 30.5 3.2 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: Centers for Disease Control, public use data tapes, 1988–1992.
 
 

Surgeon General's Report 

Table 18.	 Percentage of adult American Indian and Alaska Native smokers* who reported smoking <15, 

15–24, or ≥25 cigarettes per day, overall and by region/state, gender, age, and education, 

Behavioral Risk Factor Surveillance System, 1988–1992 aggregate data 

Northern 

 Plains†

 % ±CI

Northern 

 Woodlands† 

 % ±CI 

Alaska 

 % ±CI‡

California

Characteristic % ±CI

Total 

<15 cigarettes 83.7 4.1 88.0 5.0 70.9 7.5 84.6 3.6 

15–24 cigarettes 12.2 3.7 8.5 4.4 15.7 5.5 12.3 3.3 

≥ 25 cigarettes 4.1 2.2 3.5 2.7 13.5 6.5 3.1 1.6 

Gender 

Men 

<15 cigarettes 79.3 7.0 87.7 7.4 66.8 11.4 83.9 5.5 

15–24 cigarettes 15.2 6.1 8.3 6.4 14.3 7.8 11.7 5.0 

≥ 25 cigarettes 5.5 4.0 4.0 4.1 19.0 10.4 4.4 2.6 

Women 

<15 cigarettes 88.2 4.2 88.2 6.8 75.8 8.8 85.2 4.6 

15–24 cigarettes 9.0 3.9 8.8 5.9 17.3 7.7 12.7 4.3 

≥ 25 cigarettes 2.7 1.9 3.0 3.5 6.9 5.4 2.1 2.0 

Age (years) 

18–34 

<15 cigarettes 87.7 5.1 90.8 5.8 68.1 12.4 87.4 4.5 

15–24 cigarettes 8.7 3.8 5.4 4.4 18.8 9.5 10.9 4.2 

≥ 25 cigarettes 3.6 3.7 3.8 4.0 13.0 10.6 1.7 1.6 

35–54 

<15 cigarettes 78.5 7.4 82.1 11.0 65.6 12.0 79.5 7.4 

15–24 cigarettes 15.6 6.9 16.2 10.8 16.3 8.7 14.9 6.7 

≥ 25 cigarettes 6.0 3.5 1.7 2.5 18.1 10.6 5.6 4.0 

≥55 

<15 cigarettes 80.7 12.3 89.1 12.8 83.5 13.7 84.9 7.4 

15–24 cigarettes 16.8 12.2 5.1 9.9 8.9 9.8 12.1 6.8 

≥ 25 cigarettes 2.6 2.1 5.8 8.4 7.6 10.9 3.0 3.1 

Education§ 

Less than high school 

<15 cigarettes 85.0 7.7 90.6 9.9 66.3 14.8 81.7 7.3 

15–24 cigarettes 12.0 7.6 5.1 5.8 13.3 10.5 14.9 6.7 

≥ 25 cigarettes 3.0 2.0 4.4 8.3 20.4 13.5 3.4 3.1 

High school/any college 

<15 cigarettes 78.2 6.2 83.1 7.7 74.1 8.9 84.2 4.6 

15–24 cigarettes 15.8 5.3 13.2 7.2 16.3 7.4 12.0 4.1 

≥ 25 cigarettes 6.1 4.0 3.7 3.2 9.6 6.3 3.9 2.4 

*Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in 

their lives and who reported at the time of survey that they currently smoked. 

†

The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern 

Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes 

Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; 

and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor 

Surveillance System during this period. 

52 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Pacific
 

Northwest† 

% ±CI

Oklahoma 

 % ±CI 

Southwest†

 % ±CI

 Other†

 % ±CI

 Total


 % ±CI 

83.4 6.2 83.0 4.6 92.3 3.7 81.1 3.6 83.3 2.1 

9.7 4.6 10.8 3.8 4.5 2.3 11.5 3.1 10.4 1.7 

6.9 4.3 6.2 3.0 3.2 3.1 7.4 2.2 6.4 1.3 

83.3 9.1 80.2 7.1 87.3 7.3 74.7 5.9 79.3 3.4 

8.2 6.7 12.0 5.4 7.2 4.2 14.1 5.0 11.6 2.7 

8.5 6.5 7.8 5.0 5.6 6.4 11.1 4.0 9.1 2.3 

83.5 8.4 85.3 6.2 96.4 2.7 87.5 3.9 87.1 2.4 

10.9 6.2 9.8 5.3 2.3 2.3 8.8 3.6 9.2 2.1 

5.6 5.9 4.9 3.6 1.2 1.4 3.6 1.8 3.7 1.3 

84.0 10.0 83.5 7.2 98.1 2.1 83.5 5.6 85.9 2.9 

9.2 7.1 9.2 5.5 1.8 2.1 11.9 5.2 9.3 2.5 

6.8 7.7 7.4 5.2 0.1 0.2 4.6 2.6 4.8 1.8 

74.6 11.9 81.1 7.1 84.8 8.7 74.0 6.6 76.8 3.9 

16.0 10.9 12.8 6.2 7.0 4.4 13.3 5.0 13.7 3.3 

9.3 6.7 6.1 4.1 8.2 8.2 12.7 5.0 9.4 2.6 

90.2 8.4 86.0 11.1 87.8 11.4 87.1 6.1 87.2 4.1 

4.9 5.5 10.9 9.9 9.9 11.2 7.6 4.6 7.5 3.1 

4.8 6.8 3.1 5.6 2.3 2.7 5.3 4.3 5.3 2.8 

86.0 12.5 69.7 14.5 80.3 10.9 75.1 8.6 78.6 4.9 

9.2 10.8 22.0 13.3 16.4 10.6 11.3 6.7 11.2 3.6 

4.8 7.3 8.3 8.2 3.3 4.0 13.6 6.6 10.2 3.8 

82.2 7.0 84.7 5.1 92.0 5.4 80.3 4.5 82.1 2.7 

10.5 5.6 9.5 4.1 3.6 2.5 12.9 4.0 11.9 2.4 

7.3 4.7 5.8 3.3 4.5 5.0 6.7 2.7 6.0 1.5 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: Centers for Disease Control, public use data tapes, 1988–1992.
 

Patterns of Tobacco Use 53 
 

Surgeon General's Report 

Table 19.	 Percentage of adult American Indian and Alaska Native smokers who reported they quit 

smoking,* overall and by region/state, gender, age, and education, Behavioral Risk Factor 

Surveillance System, 1988–1992 aggregate data 

Northern 

 Plains†

 % ±CI

Northern 

 Woodlands† 

 % ±CI 

Alaska 

 % ±CI‡

California

Characteristic % ±CI

Total 37.0 6.6 44.8 11.9 31.8 8.3 44.3 6.3 

Gender

 Men 37.1 9.3 44.8 16.2 32.8 11.4 49.5 9.8

 Women 36.9 9.3 44.8 16.9 30.3 11.7 40.0 8.2 

Age (years)

 18–34 31.2 10.0 29.8 15.8 15.9 9.4 41.8 9.3

 35–54 43.8 9.8 49.2 17.3 32.2 13.4 35.5 9.7 

≥55 42.2 16.1 61.0 28.9 58.2 19.7 62.2 12.6 

Education§ 

Less than high school 38.5 12.6 53.6 22.7 35.1 15.8 48.3 13.0 

High school/any college 38.1 7.7 41.8 14.2 37.5 11.6 46.2 7.5 

*The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are 

persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that 

they were not smoking.

†The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern 

Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes 

Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; 

and “other” includes all remaining states not specified above that participated in the Behavioral Risk Factor 

Surveillance System during this period. 

Great Falls, 63 percent of men and 62 percent of women 

reported that they smoked. In both areas, rates of 

smoking were higher among persons aged 25 years 

and older than among their younger counterparts. For 

American Indians in Great Falls, those who had a high 

school education and did not go to college had lower 

rates of smoking than those with less than a high school 

education or those with some college education. Gender differences in smoking cessation were also observed. Among American Indians in Great Falls, 16 

percent of men and 19 percent of women had quit 

smoking; among the Blackfeet American Indians, 34 

percent of men and 22 percent of women had quit 

smoking (Goldberg et al. 1991). 

women (58.2 percent) with 12 or more years of education than among men (81.3 percent) and women (74.5 

percent) with less than 12 years of education. Rates of 

current smoking among the Oneida Indian Nation followed similar patterns in terms of educational status: 

men (34.7 percent) and women (29.1 percent) with 12 

or more years of education had a lower prevalence 

of cigarette smoking than men (59.4 percent) and 

women (56.9 percent) with less than 12 years of formal education. Overall, a greater proportion of men 

(44.4 percent) than women (40.0 percent) smoked. The 

prevalence of cessation, on the other hand, was fairly 

similar for men (37.9 percent) and women (38.1 

percent). 

In a 1990 study of members of the Oneida Indian 

Nation of New York, 71.6 percent of the men and 64.6 

percent of the women reported having ever smoked 

cigarettes (CDC 1990). The prevalence of ever smoking cigarettes was lower among men (65.3 percent) and 

Similar findings were observed in a survey of 

people on the Warm Springs Reservation (Warm 

Springs Confederated Tribes 1993) and in the Western 

Washington Native American Behavior Risk Factor 

Survey of the Chehalis, Hoh, Quinault, and Shoalwater 

54 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Pacific
 

Northwest† 

% ±CI

Oklahoma 

 % ±CI 

Southwest†

 % ±CI

 Other†

 % ±CI

 Total


 % ±CI 

40.7 10.2 46.8 8.0 51.2 10.3 39.8 7.0 41.5 4.0 

33.1 15.1 44.8 11.8 51.8 15.0 35.4 9.4 39.2 5.5 

47.1 13.8 48.5 11.1 50.3 13.8 46.1 10.5 44.4 5.6 

27.8 16.1 38.7 12.3 52.7 15.9 28.5 10.0 30.6 5.4 

36.9 18.0 52.7 11.7 54.1 16.7 42.2 11.9 44.0 6.6 

61.0 16.7 57.4 20.6 38.0 21.2 58.7 12.2 58.2 8.3 

45.0 23.5 40.4 18.1 40.9 19.5 39.7 15.3 42.6 8.3 

43.5 11.7 47.8 9.5 53.2 13.6 41.4 8.1 42.7 4.8 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: Centers for Disease Control, public use data tapes, 1988–1992.
 

Tribes (Kimball et al. 1990). In a survey of 1,318 adult 

American Indian and Alaska Native users of Indian 

clinics in northern California, 40 percent of the respondents reported smoking cigarettes (47 percent of 

the men and 37 percent of the women) (Hodge et al. 

1995). 

Aggregated data from the BRFSS indicate that 

among American Indian and Alaska Native women 

of reproductive age, smoking rates were highest 

among women in Alaska (43.9 percent), the Northern 

Plains (39.5 percent), and the Northern Woodlands 

(38.8 percent) and lowest among women in the Southwest (11.5 percent) and California (15.3 percent) (Table 

20) (CDC, public use data tapes, 1988–1992). 

Smokeless Tobacco Use 

to the BRFSS data for 1988–1992, the prevalences 

among men were 24.6 percent in the Northern Plains, 

16.8 percent in the Northern Woodlands, 14.3 percent 

in Oklahoma, 11.6 percent in Alaska, 6.5 percent in the 

Southwest, and 1.8 percent in the Pacific Northwest 

(CDC, public use data tapes, 1988–1992). In the Oneida 

Indian Nation survey, none of the women reported 

using smokeless tobacco, whereas 17.3 percent of the 

men reported using it (CDC 1990). 

The use of smokeless tobacco (chewing tobacco 

and snuff) among American Indians and Alaska 

Natives also has varied by state and region. According 

More recently, investigators have reported extremely high rates of smokeless tobacco use among 

Lumbee women in North Carolina (CDC 1995). In 

1991, the prevalence of smokeless tobacco use was 

greatest among Lumbee women 65 years of age and 

older (51 percent) and lowest among those 25–34 years 

of age (6 percent). The prevalence was also high among 

women with less than 12 years of education (42 

percent). 

Patterns of Tobacco Use 55 
 

Surgeon General's Report 

Table 20.	 Percentage of American Indian and Alaska Native women of reproductive age who reported 

being current cigarette smokers,* overall and by region/state, Behavioral Risk Factor Surveillance 

System, 1988–1992 aggregate data 

Alaska California

Northern 

Plains†

Northern

 Woodlands† 

% +CI‡ % +CI % +CI % +CI 

43.9 9.3 15.3 9.1 39.5 12.3 38.8 7.1 

Total

Oklahoma 

Pacific 

Northwest† Southwest† Other† 

% +CI 

24.9 3.9 

% +CI % +CI % +CI % +CI 

30.4 12.5 32.6 9.7 11.5 5.4 26.7 7.1 

*Current cigarette smokers are women aged 18–44 years who reported smoking at least 100 cigarettes in their 

lives and who reported at the time of survey that they currently smoked. 

†

The Northern Plains region includes Montana, Nebraska, North Dakota, and South Dakota; the Northern
 

Woodlands region includes Iowa, Michigan, Minnesota, and Wisconsin; the Pacific Northwest region includes
 

Idaho, Oregon, and Washington; the Southwest region includes Arizona, Colorado, New Mexico, and Utah; and
 

“other” includes all remaining states not specified above that participated in the Behavioral Risk Factor
 

Surveillance System during this period.


‡

95% confidence interval.
 

Source: Centers for Disease Control, public use data tapes, 1988–1992.
 

Asian Americans and Pacific Islanders 

Data needed to assess long-term trends in cigarette 

smoking among Asian Americans and Pacific Islanders 

have been unavailable because U.S. surveys, census data, 

and other national databases have not always included 

detailed descriptions of race/ethnicity. Although data 

from specific Asian American and Pacific Islander groups 

and state surveys have provided information about cigarette smoking for certain racial/ethnic subgroups, these 

data have been limited in quantity and quality. The NHIS 

first included information about Asian Americans and 

Pacific Islanders in the 1978 survey. However, because 

the proportion of Asian Americans and Pacific Islanders 

in the United States is small, data from several years must 

be aggregated to increase the precision of estimates. Because of small sample sizes and aggregation of data, 

racial/ethnic subgroup differences in smoking behavior are masked. These differences are important because 

the category Asian American and Pacific Islander is heterogeneous in both culture and health behaviors. For example, this category includes about 32 different national 

and racial/ethnic subgroups (Austin et al. 1989; Hawks 

1989) and nearly 500 languages and dialects (Chen 1993), 

and smoking patterns among these subgroups vary. 

Prevalence of Cigarette Smoking 

Between 1978 and 1995, the prevalence of smoking declined among Asian Americans and Pacific Islanders, according to NHIS data (Table 21) (NCHS, 

public use data tapes, 1978–1995). However, patterns 

between men and women differed. The cigarette 

smoking prevalence among Asian American and Pacific Islander men declined slightly, from 32.5 to 25.1 

percent, whereas the prevalence of smoking among 

Asian American and Pacific Islander women declined 

approximately 60 percent, from 14.7 to 5.8 percent. 

Throughout this period, the prevalence of smoking 

among men remained more than twice that among 

women; in 1994–1995, men were 4.3 times more likely 

than women to report current smoking. 

Number of Cigarettes Smoked Daily 

From 1978 through 1995, the percentage of Asian 

American and Pacific Islander smokers who smoked 

fewer than 15 cigarettes per day increased significantly, 

according to the NHIS data (Table 22) (NCHS, public use 

data tapes, 1978–1995). Although large declines from 

1978–1980 to 1992–1993 were observed in the prevalence 

56 Chapter 2 
 

 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 21.	 Percentage of adult Asian Americans and Pacific Islanders who reported being current cigarette 

smokers,* overall and by gender, age, and education, National Health Interview Surveys, United 

States, 1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 23.8 4.0 21.4 3.4 15.8 2.4 16.1 2.5 16.7 2.7 15.3 3.0 

Gender 

Men 32.5 4.5 33.0 6.2 22.5 3.8 24.5 4.0 26.8 4.7 25.1 5.2 

Women 14.7 6.6 9.6 3.5 9.2 2.8 6.6 2.0 6.8 2.7 5.8 2.3 

Age (years) 

18–34 22.5 5.8 21.6 4.6 16.3 3.5 15.5 3.2 15.7 4.2 17.6 5.3 

35–54 28.7 8.5 20.8 4.8 16.1 3.6 17.1 4.6 21.0 4.7 15.5 4.3 

>55 17.4 4.7 22.0 8.6 12.7 5.9 15.7 5.4 8.3 5.4 9.2 5.1 

Education§ 

Less than high school 23.1 8.9 23.8 10.2 17.9 6.5 24.9 7.4 13.4 6.2 13.3 7.9 

High school/any college 23.7 3.9 22.6 4.5 16.7 2.8 15.6 2.9 17.6 3.5 14.4 3.2 

*Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978–1991, 

current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked. For 1992–1995, current smokers include persons 

who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they 

currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

of smoking 25 or more cigarettes per day, recent estimates	 

are imprecise and should be interpreted with caution.	 

Islanders aged 18 years and older who were daily smokers one year before the survey, 57.8 percent reported that 

they were still smoking daily and that they had not tried 

quitting for at least one day during the previous year 

(Table 4). Another 32.0 percent had tried quitting for at 

least one day, 4.8 percent were occasional smokers (i.e., 

smoked only on some days), 2.5 percent had not smoked 

for the past 1–90 days, and 2.9 percent had not smoked 

for the past 91–364 days. Among current smokers, Asian 

Americans and Pacific Islanders were slightly more likely 

than whites to report trying to quit for at least a day during the previous year. 

Quitting Behavior 

Between 1978 and 1995, the percentage of Asian 

Americans and Pacific Islanders who have ever smoked 

100 cigarettes and have quit smoking increased somewhat, NHIS data indicate (Table 23) (NCHS, public use 

data tapes, 1978–1995). The prevalence of cessation 

among women increased from 1987–1988 to 1994–1995, 

but no consistent pattern was observed among men. 

During each survey period, the prevalence of cessation 

was higher among Asian Americans and Pacific Islanders 55 years of age and older than it was among their 

younger counterparts (Table 23). 

Women of Reproductive Age 

The prevalence of current smoking among Asian 

American and Pacific Islander women of reproductive 

age (18–44 years) has decreased substantially over 

Data from the NCI Supplement of the 1992–1993 

CPS indicate that among Asian Americans and Pacific 

Patterns of Tobacco Use 57 
 

 

<

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<

 

<

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Surgeon General's Report 

Table 22.	 Percentage of adult Asian American and Pacific Islander smokers* who reported smoking <15, 

15–24, or >25 cigarettes per day, overall and by gender, age, and education, National Health 

Interview Surveys, United States, 1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 

<15 cigarettes 43.3 11.7 53.7 8.1 55.6 7.8 60.4 8.1 61.8 9.4 70.6 9.8 

15–24 cigarettes 37.0 9.7 35.3 8.5 37.4 7.4 33.8 7.6 37.1 9.4 21.4 8.2 

>25 cigarettes 19.7 6.5 11.0 6.5 7.0 3.3 5.8 3.9 1.0 1.3 8.0 6.5 

Gender 

Men 

<15 cigarettes 40.1 14.6 54.4 9.4 51.8 9.6 59.2 9.2 58.4 11.2 69.1 11.5 

15–24 cigarettes 35.8 11.1 36.2 9.3 41.2 9.2 35.4 8.6 40.9 11.2 23.6 10.0 

>25 cigarettes 24.1 8.2 9.4 6.6 7.0 4.2 5.5 4.4 0.7 1.4 7.3 7.4 

Women 

<15 cigarettes 50.4 13.7 51.1 14.9 64.4 11.3 65.8 16.8 75.4 11.6 77.3 13.9 

15–24 cigarettes 39.6 12.8 32.0 15.2 28.5 9.8 26.8 16.5 22.2 11.5 11.5 11.0 

>25 cigarettes 10.0 7.7 16.8 10.1 7.1 5.1 7.4 8.3 2.3 3.3 11.2 11.1 

Age (years) 

18–34 

<15 cigarettes 42.2 12.2 48.2 10.4 59.0 11.0 60.3 10.7 61.3 13.7 73.2 13.6 

15–24 cigarettes 37.3 11.5 40.5 11.5 35.1 10.5 35.2 10.5 38.2 13.7 24.3 13.2 

>25 cigarettes 20.5 8.2 11.3 8.3 5.9 4.4 4.5 3.8 0.6 1.1 2.5 3.9 

35–54 

<15 cigarettes 45.0 17.1 54.9 13.5 54.5 10.9 62.9 13.5 63.6 13.0 65.0 15.2 

15–24 cigarettes 35.5 15.0 32.2 13.1 40.4 11.0 26.9 10.5 34.9 12.9 22.3 11.8 

>25 cigarettes 19.5 9.0 12.9 8.1 5.1 4.6 10.1 9.2 1.6 2.3 12.8 14.0 

>55 

<15 cigarettes 41.3 18.5 67.9 20.3 41.5 23.2 55.8 18.5 52.7 39.1 78.0 23.9 

15–24 cigarettes 40.9 13.1 26.4 18.4 39.4 25.0 43.3 18.5 47.3 39.1 4.7 9.3 

>25 cigarettes 17.9 14.4 5.7 8.2 19.1 16.5 0.9 1.8 0.0 0.0 17.3 23.4 

Education§ 

Less than high school 

<15 cigarettes 59.6 21.3 66.0 15.2 48.7 19.6 72.9 13.9 80.2 17.3 73.8 32.2 

15–24 cigarettes 28.6 18.0 23.3 14.2 42.4 19.8 22.2 13.3 19.8 17.3 6.2 9.5 

>25 cigarettes 11.8 13.2 10.7 9.8 8.9 9.5 4.8 6.0 0.0 0.0 20.0 32.8 

High school/any college 

<15 cigarettes 40.4 12.4 47.6 9.6 53.0 8.4 58.1 9.8 62.2 11.4 64.8 12.0 

15–24 cigarettes 39.4 11.8 39.3 10.2 39.4 8.2 34.7 9.3 36.7 11.4 26.5 10.7 

>25 cigarettes 20.2 7.4 13.0 8.1 7.6 4.2 7.2 5.5 1.1 1.6 8.7 7.5 

*Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978–1991, 

current cigarette smokers included persons who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked. For 1992–1995, current smokers included persons 

who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they 

currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

58 Chapter 2 
 

 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 23.	 Percentage of adult Asian American and Pacific Islander ever smokers who have quit,* overall 

and by gender, age, and education, National Health Interview Surveys, United States, 1978–1995 

aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 39.9 6.5 38.4 6.5 41.2 5.7 49.0 5.3 45.5 6.5 48.3 7.2 

Gender 

Men 41.2 6.1 34.2 7.8 42.7 6.9 47.2 6.4 42.2 7.4 43.3 8.7 

Women 36.9 14.0 49.6 10.2 37.2 9.6 55.4 10.1 55.0 13.9 62.2 12.8 

Age (years) 

18–34 34.5 9.4 25.8 7.5 31.3 7.7 34.1 7.6 30.7 9.6 28.5 10.9 

35–54 35.7 13.5 45.5 8.8 46.3 8.0 55.3 9.5 44.1 9.2 55.5 10.1 

>55 59.4 10.6 48.9 16.5 58.1 14.9 60.5 11.0 76.9 13.2 70.2 14.9 

Education§ 

Less than high school 37.0 18.7 46.1 17.1 30.1 15.3 37.7 13.3 50.4 18.1 50.3 21.9 

High school/any college 45.2 7.2 39.2 7.3 46.7 6.4 54.8 6.5 48.2 7.3 53.7 8.2 

*Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. The prevalence of 

cessation is the percentage of ever smokers who are former smokers. Former smokers are persons who 

reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they were 

not smoking, and ever smokers include current and former smokers.

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

time, from 16.0 percent in 1978–1980 to 5.7 percent in 

1994–1995, NHIS data indicate (Table 24) (NCHS, public use data tapes, 1978–1995). Overall, the greatest 

change occurred between 1978 and 1985, when the 

prevalence of current smoking declined by approximately 50 percent. Since 1985, declines in smoking 

prevalence have slowed. 

Recent birth certificate data from U.S. final 

natality statistics indicate that 3.4 percent of Asian 

American and Pacific Islander mothers smoked during pregnancy (Table 6). Smoking rates for pregnant 

Asian American and Pacific Islander women are generally low—between 0.8 and 5.2 percent for Chinese, 

Japanese, Filipino, and “other” Asian Americans or 

Pacific Islanders. Hawaiian mothers, however, have a 

relatively high smoking rate (15.9 percent). Ventura 

and colleagues (1995) reported that 3 percent of 

foreign-born Asian American and Pacific Islander 

mothers were reported as smokers, compared with 13 

percent of their United States-born counterparts. Data 

on tobacco use among these mothers (except Hawaiians) may be skewed because California and New York 

do not report this information, and together these states 

account for nearly half of births in each Asian American and Pacific Islander subgroup (Ventura et al. 1996). 

Young People 

Cigarette Smoking 

Data from MTF surveys—one of the few studies 

with data on smoking prevalence among Asian American and Pacific Islander youths—show that these 

youths have a lower prevalence of smoking than their 

counterparts in all other racial/ethnic groups except 

African Americans (Table 7). According to the 1990– 

1994 MTF data on male high school seniors, the 

prevalence of smoking was 11.6 percent among African Americans, 20.6 percent among Asian Americans 

and Pacific Islanders, 28.5 percent among Hispanics, 

33.4 percent among whites, and 41.1 percent among 

Patterns of Tobacco Use 59 
 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 16.0 6.7 8.2 3.3 8.8 2.7 6.0 2.4 6.6 2.8 5.7 3.0 

Education§ 

Less than high school 15.0 26.4 7.0 7.3 9.8 8.0 14.1 9.1 3.5 4.0 2.3 4.6 

High school/any college 15.4 6.9 8.6 3.4 9.6 3.4 6.1 3.1 5.7 3.1 5.8 3.5 

Surgeon General's Report 

Table 24.	 Percentage of adult Asian American and Pacific Islander women of reproductive age who reported 

being current cigarette smokers,* overall and by education, National Health Interview Surveys, 

United States, 1978–1995 aggregate data 

*Excludes Asian Americans and Pacific Islanders who indicated they were of Hispanic origin. For 1978–1991, 

current cigarette smokers include women aged 18–44 years who reported smoking at least 100 cigarettes in 

their lives and who reported at the time of survey that they currently smoked. For 1992–1995, current smokers 

include women aged 18–44 years who reported smoking at least 100 cigarettes in their lives and who reported 

at the time of survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

American Indians and Alaska Natives. Data on 

female high school seniors show that the prevalence 

of smoking was 8.6 percent among African Americans, 

13.8 percent among Asian Americans and Pacific Islanders, 19.2 percent among Hispanics, 33.1 percent 

among whites, and 39.4 percent among American Indians and Alaska Natives. As reported by Bachman 

and colleagues (1991a), during 1985–1989, patterns of 

daily smoking were similar, with prevalence estimates 

being lowest among African Americans and Asian 

Americans and Pacific Islanders. Among Asian 

American and Pacific Islander high school seniors, 4.4 

percent of males and 4.5 percent of females reported 

smoking one-half pack or more per day. 

In 1993, Wiecha (1996) surveyed public school 

students from two middle schools and two high 

schools in Worcester, Massachusetts. The selfadministered questionnaire used items from 

CDC’s YRBS; every question was written in English, 

Vietnamese, and Spanish. Vietnamese males were as 

likely to report cigarette smoking (27.9 percent) as were 

white males (28.3 percent). The prevalence of cigarette smoking among Vietnamese females (3.7 percent) 

was lower than among African American (15.1 percent), Hispanic (29.7 percent), and white (30.6 percent) 

females. Length of time in the United States was related to smoking prevalence for males aged 17 years 

and older: cigarette smoking prevalence was 7.7 percent among those who had been in the United States 

for at least six years and 45.2 percent for those who 

had been in the United States for less than six years. 

Smokeless Tobacco Use 

Wiecha (1996) also queried Worcester students 

about their use of smokeless tobacco products. The 

prevalence of previous-month use among males was 

12.0 percent for Vietnamese, 10.3 percent for African 

Americans, 10.8 percent for Hispanics, and 20.5 percent for whites. Previous-month use among females 

was 3.6 percent for Vietnamese, 3.2 percent for African Americans, 1.9 percent for Hispanics, and 2.7 percent for whites. Small sample sizes limit the precision 

of some of these estimates. 

State and Local Smoking Estimates 

Among the diverse subgroups of Asian Americans and Pacific Islanders, wide variations in lifestyles, 

health behaviors, and health practices are evident. 

State and local survey data illustrate the distinct variations in cigarette smoking patterns and behaviors 

among these ethnic subgroups (Klatsky and 

60 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Armstrong 1991; CDC 1992c; Blaisdell 1993; McPhee 

et al. 1993; McPhee et al. 1995; Wewers et al. 1995; 

Jenkins et al. 1997b). Although prevalence estimates 

from national surveys indicate that the smoking prevalence among Asian Americans and Pacific Islanders is 

lower than the prevalence of smoking in all other 

racial/ethnic groups and in the overall U.S. population, state and local surveys show that these estimates 

vary dramatically between racial/ethnic subgroups of 

Asian Americans and Pacific Islanders. Racial/ethnic 

subgroup-specific information on smoking behaviors 

is needed because broad groupings of these many distinct racial/ethnic groups mask important differences. 

To characterize smoking and other risk behaviors more fully for program planning efforts at the local level, the California State Department of Health 

Services and two California agencies—Asian Health 

Services and the University of California, San Francisco, Vietnamese Health Promotion Project—adapted 

versions of the CDC’s Behavioral Risk Factor Surveys 

for use with Chinese and Vietnamese residents. The 

questionnaires were modified for cultural appropriateness and translated into Chinese or Vietnamese. 

The Chinese-language survey included face-to-face 

interviews with 296 Chinese adults in Oakland, California, between June 1989 and February 1990. In the 

Vietnamese-language survey, telephone interviews 

were conducted with 1,011 Vietnamese adults during 

February and March 1991 (CDC 1992b). Among both 

Chinese and Vietnamese respondents, men were more 

likely than women to be current smokers. The highest smoking prevalence was among men aged 25–44 

years, and the prevalence of smoking was lower among 

men with higher levels of education (Table 25) (CDC 

1992b). The mean number of cigarettes smoked per 

day by smokers was 15.9 among Chinese men, 11.0 

among Vietnamese women, and 10.1 among Vietnamese men. This number declined with older age and 

increasing levels of education and income. (Data on 

Chinese women are unavailable because the number 

of Chinese women who smoked was too small for 

analysis.) 

These surveys also measured acculturation by 

using several proxy variables, including the percentage of lifetime spent in the United States, fluency in 

English, and date of immigration. Among Chinese 

men, the average number of cigarettes smoked per day 

increased as the percentage of their lifetime spent in 

the United States increased (Table 25). Among Vietnamese respondents, the prevalence of smoking was 

higher among men who immigrated in 1981 or later 

and who were not fluent in English. 

In a more recent statewide telephone survey of 

32,125 California households, Burns and Pierce (1992) 

found that overall, the prevalence of smoking was 

lower among Asian Americans and Pacific Islanders 

than among whites, African Americans, and Hispanics. This trend was evident among both men and 

women. Because the survey was conducted only in 

English or Spanish, Asian Americans and Pacific Islanders with limited English fluency were unable to 

participate. This exclusion of recent immigrants and 

those with the lowest levels of acculturation may have 

produced a biased estimate of the prevalence of cigarette smoking among California’s Asian Americans 

and Pacific Islanders. In assessing the smoking prevalence for several racial/ethnic subgroups, Burns and 

Pierce (1992) found that Chinese reported the lowest 

prevalence of smoking (11.7 percent), whereas Koreans reported the highest prevalence (23.5 percent) 

(Table 26). Men in all racial/ethnic subgroups were 

substantially more likely than women to smoke cigarettes. For men, the prevalence of smoking was highest among Koreans (35.8 percent) and lowest among 

Chinese (19.1 percent). The prevalence of smoking was 

highest among men aged 25–44 years. Smoking prevalence declined substantially with increasing education 

across all racial/ethnic subgroups of men except Japanese men. For women, the prevalence of smoking was 

highest among Japanese (14.9 percent) and Koreans 

(13.6 percent) and lowest among Chinese (4.7 percent). 

Smoking prevalence declined with increasing level of 

education across all racial/ethnic subgroups of women 

except Chinese. 

In a 1978–1985 survey of 13,031 persons of Asian 

ancestry enrolled in the Oakland, California, Kaiser 

Permanente Medical Care Program, the prevalence of 

cigarette smoking varied significantly by Asian subgroup for both men and women (Klatsky and 

Armstrong 1991). Among men, the prevalence of cigarette smoking was highest among Filipinos (32.9 percent) and lowest among Chinese (16.2 percent) (Table 

27). Among women, the prevalence of smoking was 

highest among Japanese (18.6 percent) and lowest 

among Chinese (7.3 percent). Japanese men and 

women were more likely to smoke one or more packs 

of cigarettes per day than were their counterparts in 

other racial/ethnic groups. 

During 1989, newly arrived Southeast Asian immigrants were surveyed by the Health Department in 

King County, Washington, regarding health problems 

and health risk behaviors (CDC 1992c). Investigators 

analyzed medical interview records for 274 Vietnamese, 147 Laotian, and 112 Cambodian immigrants and 

found that the smoking prevalence was substantially 

Patterns of Tobacco Use 61 
 

 

 

Surgeon General's Report 

Table 25.	 Percentage of Chinese and Vietnamese men who reported they smoke* and the number of 

cigarettes they smoke per day, by age, education, annual household income, and level of 

acculturation, Behavioral Risk Factor Surveillance System, California, 1990 and 1991 

aggregate data 

Chinese	 Vietnamese 

Mean no. Mean no. 

Characteristic % ±CI† cigarettes ±CI % ±CI cigarettes ±CI 

Age (years) 

1–24 ‡ ‡ ‡ ‡ 12.3 8.5 10.0 6.5 

25–44 38.5 15.3 12.6 9.1 42.4 5.3 10.3 1.3 

45–64 28.1 15.6 22.6 12.4 27.4 7.5 9.9 1.7 

≥ 65 24.4 12.6 15.4 7.5 23.3 15.2 7.3 3.0 

Education 

Eighth grade or less 30.2 12.4 15.7 5.5 36.6 11.2 11.9 2.9 

Some high school 45.5 20.9 11.2 4.5 39.6 8.3 10.6 1.7 

High school graduate 

Some college 

College or more 

28.6 19.4 28.0 28.4 40.4 12.8 8.8 2.4 

0.0 ‡ 0.0 ‡ 32.9 7.3 9.9 2.1 

20.0 17.5 10.0 ‡ 26.8 7.7 9.1 2.7 

Annual household income

 <$10,000 25.5 12.0 9.5 3.9 38.7 11.1 10.3 2.1 

$10,000–$24,999 32.1 12.6 14.7 2.7 29.9 7.2 10.1 2.0 

$25,000–$50,000 20.0 22.4 55.0 ‡ 36.9 7.8 10.1 1.9

 >$50,000 ‡ ‡ ‡ ‡ 29.5 10.1 8.3 3.3 

Acculturation

 <25% of lifetime in United States 29.8 9.8 13.0 3.7 NA NA NA NA 

≥ 25% of lifetime in United States 26.2 13.3 22.3 15.9 NA NA NA NA 

Fluent in English§ 

Not fluent in English§ 

‡ ‡ ‡ ‡ 29.7 7.6 10.7 2.6 

31.8 8.8 13.3 3.1 36.6 4.6 10.0 1.1 

Immigration before 1981 NA NA NA NA 32.2 5.3 10.5 1.5 

Immigration in 1981 or later NA NA NA NA 37.7 6.0 9.8 1.5 

*Current cigarette smokers are men who reported smoking at least 100 cigarettes in their lives and who reported 

at the time of survey that they currently smoked. Because the number of current smokers who were women 

was too small for analysis, data for age, education, annual income, and acculturation are provided for men only. 

†

95% confidence interval. 

‡

Numbers too small for analysis.


§

Self-report of ability to speak English well or fluently.
 

NA = data not available.
 

Source: Centers for Disease Control 1992b.
 

higher among men (42.5 percent) than among women 

(5.7 percent) (Table 27). Southeast Asian men were 1.6 

times as likely to smoke as were other men in Washington, whereas Southeast Asian women were onefourth as likely to smoke as were other women in the 

state (CDC 1992c). 

61.1 percent of pure Native Hawaiian men and 56.3 

percent of part Native Hawaiian men were current 

smokers (Table 27). According to the 1985 BRFSS data, 

42 percent of Native Hawaiian men and 34 percent of 

Native Hawaiian women were current smokers. Data 

from the 1989 BRFSS in Hawaii indicate that the 

prevalence was 28.2 percent among Native Hawaiians 

(Table 27), which was higher than that among Filipinos, Japanese, and whites (Blaisdell 1993). 

In a recent review of Hawaii’s health surveillance 

data for 1975–1980, Blaisdell (1993) found that the 

smoking prevalence was higher among Native Hawaiians than among persons in other racial/ethnic groups; 

62 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 26.	 Percentage of adult Asian Americans and Pacific Islanders who reported being current smokers,* 

overall and by gender, age, and education, Screener Survey, California, 1990 and 1991 aggregate 

data† 

Characteristic Chinese (%) Filipinos (%) Japanese (%) Koreans (%) All Asians (%) 

Total 11.7 15.9 17.4 23.5 15.9 

Age (years) 

18–24 9.7 12.2 19.7 26.9 14.6 

25–44 12.4 21.0 20.3 26.1 18.1 

45–64 11.4 14.4 16.8 16.2 15.3 

>65 11.4 6.6 9.9 23.2 8.9 

Education 

Less than high school 17.6 19.2 23.4 38.1 21.4 

High school 16.7 20.3 21.5 21.3 19.4 

Some college 11.2 15.2 16.2 25.3 15.2 

College 6.6 11.2 12.3 19.1 10.5 

Men 

Total 19.1 24.0 20.1 35.8 23.5 

Age (years) 

18–24 13.0 19.1 17.2 34.3 19.0 

25–44 20.9 29.2 24.7 44.1 27.1 

45–64 19.9 25.8 22.1 22.6 24.0 >65 19.8 10.6 11.1 60.6 14.0 

Education 

Less than high school 35.4 32.1 18.4 70.6 36.9 

High school 26.3 27.6 28.7 35.3 28.3 

Some college 18.1 21.5 19.2 32.4 20.9 

College 9.8 18.9 16.5 31.0 15.6 

Women 

Total 4.7 8.9 14.9 13.6 8.9 

Age (years) 

18–24 5.8 4.0 22.9 19.9 9.5 

25–44 5.5 14.6 16.3 13.9 10.4 

45–64 2.5 5.1 13.4 9.9 7.4 

>65 2.6 3.4 8.3 NA 3.8 

Education 

Less than high school 1.7 11.6 28.8 20.9 9.4 

High school 9.8 12.7 17.5 14.4 12.6 

Some college 4.8 8.7 13.4 19.4 9.5 

College 3.2 4.9 7.0 5.2 4.9 

*Current cigarette smokers are persons aged 18 years and older who reported smoking at least 100 cigarettes in 

their lives and who reported at the time of survey that they currently smoked. Only English-speaking persons 

were interviewed. 

†

The variables needed to compute confidence intervals were not available.
 

NA = data not available.
 

Source: Burns and Pierce 1992.
 

Patterns of Tobacco Use 63 
 

Table 27.	 Summary of selected findings on the percentage of Asian American and Pacific Islander adults 

who smoke, overall and by gender, 1975–1995 

Sources Location/Year

Study Population 

 Characteristics 

Adults _____________________________ 

Total Men Women 

Klatsky and 

Armstrong 

1991 

CDC 1992c 

Blaisdell 1993 

McPhee et al. 

1993 

McPhee et al. 

1995 

Wewers et al. 

1995 

CDC 1997a 

Jenkins et al. 

1997b 

Jenkins et al. 

1997b 

California, 

1978–1985 

Washington State, 

1989 

Hawaii, 1975–1980 

Hawaii, 1975–1980 

Hawaii, 1985 

Hawaii, 1989 

San Francisco and 

Alameda Counties, 

California, 

1987, 1989 

Santa Clara County, 

California, 1990 

Franklin County, 

Ohio, 1992 

Alameda County, 

California, 

1994–1995 

San Francisco and 

Alameda Counties, 

California, 1990 

Houston, Texas 

1990, 1992 

Current smokers 

Chinese 

Filipino 

Japanese 

Other Asians 

Persons who smoke >1 pack/day 

Chinese 

Filipino 

Japanese 

Other Asians 

Southeast Asians, by 

age (years) 

18–29 

30–39 

40–59 >60 

Total 

Pure Native Hawaiians 

Part Native Hawaiians 

Native Hawaiians 

Native Hawaiians 

Vietnamese adults 

1987 

1989 

Vietnamese men 

Cambodians 

Laotians 

Vietnamese 

Korean adults 

Vietnamese men 

Vietnamese men 

1990 

1992 

NA 16.2 7.3 

NA 32.9 11.4 

NA 22.7 18.6 

NA 30.9 12.6 

NA 4.1 1.3 

NA 7.1 1.7 

NA 8.2 4.6 

NA 6.7 1.6 

17.6 29.5 3.0 

26.3 53.7 5.6 

26.6 54.5 8.3 

28.9 55.9 7.1 

23.1 42.5 5.7 

NA 61.1 NA 

NA 56.3 NA 

NA 42 34 

28.2 NA NA 

NA 56 9 

NA 45 2 

NA 36 NA 

20.6* 34.0 6.6 

(30.3)✝ (38.8) (21.5) 

27.8 45.6 4.2 

(32.9) (48.2) (10.8) 

27.6 43.3 6.0 

(29.0) (43.3) (9.3) 

21 39 6 

NA 36.1 NA 

NA 39.6 NA 

NA 40.9 NA 

Surgeon General's Report 

*Figures not in parentheses are from self-report. 

†

Figures in parentheses represent cotinine-adjusted prevalences. Persons whose saliva cotinine levels were 

> 14 ng/mL were considered to be smokers. 

NA = data not available. 

64 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Data collected from several surveys (conducted 

in 1987, 1989, 1990, and 1992) of Vietnamese men and 

women living in California, Texas, and Ohio showed 

that the prevalence of cigarette smoking was substantially higher among Vietnamese men than among all 

U.S. men (Jenkins et al. 1990; McPhee et al. 1993; 

McPhee et al. 1995; Wewers et al. 1995; Jenkins et al. 

1997b). Vietnamese women, however, were significantly less likely to smoke than were Vietnamese men 

or other U.S. women (Table 27). 

Several surveys have been conducted in San 

Francisco and Alameda Counties, California. In the 

1987 survey, which included data from 215 randomly 

sampled Vietnamese, 56 percent of Vietnamese men 

reported smoking cigarettes, compared with 9 percent 

of Vietnamese women (Jenkins et al. 1990). Vietnamese men had twice the smoking prevalence of men in 

the United States. On average, however, the number 

of cigarettes smoked per day was smaller among Vietnamese men (13.4) than among men in the general U.S. 

population (23.0). In the 1989 survey of 151 Vietnamese adults, 45 percent of Vietnamese men and 2 percent of Vietnamese women reported being cigarette 

smokers (Table 27) (McPhee et al. 1993). The precision 

of the estimates of smoking prevalence from the 

1987 and 1989 surveys is limited by small sample sizes. 

In the 1990 survey of 1,133 Vietnamese men, which 

served as the baseline measure in an evaluation of a 

community-based smoking cessation intervention, 36.1 

percent were current smokers. These men smoked an 

average of 11.1 cigarettes per day (Jenkins et al. 1997b). 

Another survey of Vietnamese men (n = 1,322), 

which also served as the 1990 baseline measure in an 

evaluation of a similar smoking cessation intervention, 

was conducted in Santa Clara County, California. In 

this population, 37.9 percent were current smokers; the 

smokers consumed an average of 9.9 cigarettes per day 

(McPhee et al. 1995). The comparison data for the two 

evaluation studies conducted by McPhee and colleagues 

were obtained from surveys of Vietnamese men living 

in Houston, Texas (McPhee et al. 1995; Jenkins et al. 

1997b). In the 1990 survey (n = 1,581), 39.6 percent of the 

men were current smokers; in the 1992 survey (n = 1,209), 

40.9 percent were current smokers. The mean number 

of cigarettes smoked daily was significantly lower in 1992 

(11.9) than in 1990 (13.2). 

immigrated to the United States (McPhee et al. 1995; 

Jenkins et al. 1997b). Data collected from 1,403 Southeast Asian immigrant men and women through a 

household interview indicate that self-reported cigarette smoking prevalence is underreported, especially 

among women (Wewers et al. 1995). Cigarette smoking status among Cambodian, Laotian, and Vietnamese adults in Franklin County, Ohio, was verified by 

saliva cotinine assay; a cutoff of 14 ng/mL was used 

to indicate active smoking. Self-reported smoking 

prevalence was 40.9 percent for men and 5.6 percent 

for women. However, results from biochemical 

verification indicated that 43.7 percent of men and 

14.8 percent of women were current smokers. 

Misclassification as a result of exposure to environmental tobacco smoke is unlikely, given how high the 

cotinine levels were among self-reported former and 

never smokers (range 17–331 ng/mL). As other studies have found, current smoking was substantially 

higher among men than women for all racial/ethnic 

groups in the study (Table 27) and was higher among 

respondents with less education. 

The 1990 and 1992 survey data showed an association between cigarette smoking prevalence and 

acculturation. In multivariate analyses that included 

statistical control for education, employment, and poverty status, the prevalence of cigarette smoking was 

elevated among persons with limited English-language proficiency and persons who had more recently 

From August 1994 to February 1995, a telephone 

survey of 676 Korean Americans (aged 18 years and 

older) was conducted in Alameda County, California 

(Table 27) (CDC 1997a) . Overall, 39 percent reported 

that they had smoked at least 100 cigarettes in their 

lifetimes. Men (70 percent) were more likely than 

women (13 percent) to have smoked at least 100 lifetime cigarettes. Current smoking prevalence was 39 

percent for Korean American men in Alameda 

County—an estimate that was substantially higher 

than the 19 percent prevalence estimate (from the 1995 

California Behavioral Risk Factor Survey) for all men 

in the state. Conversely, only 6 percent of Korean 

American women from Alameda County reported 

current smoking—less than the statewide estimate for 

women of 14 percent. 

Cigarette Smoking in Asian Countries 

Because so many Asian Americans have recently 

immigrated to the United States, understanding how 

smoking practices in Asian countries may affect smoking practices among Asian Americans here is important. Currently, however, data are scarce on smoking 

trends in the countries from which Asian Americans 

and Pacific Islanders have emigrated. The information that is available suggests that the prevalence of 

smoking among men in Asia is much higher than 

among Asian American men. 

Various studies from Asian countries indicate a 

very high cigarette smoking prevalence among men 

Patterns of Tobacco Use 65 
 

Surgeon General's Report 

and a relatively low prevalence among women (Weng 

et al. 1987; Li et al. 1988; Hawks 1989; Koong et al. 1990; 

Gong et al. 1995; Jenkins et al. 1997a; World Health 

Organization, unpublished data). In many of these 

countries, the estimated prevalence of smoking among 

men exceeds 50 percent. However, the prevalence of 

smoking among women is generally below 20 percent. 

Some of these studies indicate that the prevalence of 

smoking among women increases with age (Weng et 

al. 1987; Koong et al. 1990). In Pacific Island nations, 

the prevalence of smoking among men is also very 

high, with estimates generally exceeding 50 percent, 

similar to those in Asian countries. Women in the Pacific Island nations are less likely to smoke than men, 

but they are more likely to smoke than women in Asian 

countries, with prevalence estimates generally exceeding 20 percent (World Health Organization, unpublished data). 

Studies also show that smoking prevalences are 

much higher among Chinese male adolescents than 

among female adolescents. In a 1988 survey of 8,437 

junior high school students and 3,823 senior high 

school students in Beijing, the self-reported prevalence 

of ever smoking was 34.4 percent among male junior 

high school students and 3.9 percent among their female counterparts (Zhu et al. 1992). Among senior high 

school students, the prevalence of ever smoking was 

46.0 percent among males and 5.5 percent among females (Wang et al. 1994). 

Hispanics 

through retrospective analysis of smoking prevalence 

among successive birth cohorts of Hispanics (Escobedo 

and Remington 1989; Escobedo et al. 1989a). 

No data are available on long-term trends in the 

prevalence of cigarette smoking among Hispanics in 

the United States. Before 1978, major U.S. government 

databases, surveys, and publications limited their classifications of race and ethnicity to “white” and “black,” 

and no information was available about persons of 

Hispanic ancestry. When questions about Hispanic 

ancestry were added to the NHIS in 1978, direct estimates of smoking prevalence among Hispanics were 

possible for the first time. Because Hispanics made 

up a small proportion of the U.S. population at the 

time of the initial surveys, survey data must be aggregated from several years to provide meaningful 

estimates. As with previous sections, data in this section are from the NHISs, which included Hispanic 

data aggregated as follows: (1) 1978, 1979, and 1980; 

(2) 1983 and 1985; (3) 1987 and 1988; (4) 1990 and 1991; 

(5) 1992 and 1993; and (6) 1994 and 1995. Not until the 

HHANES was administered from 1982 through 1984 

was a large enough sample of Hispanics available to 

assess long-term reconstructed trends in smoking 

Prevalence of Cigarette Smoking 

NHIS data indicate that the prevalence of smoking declined among Hispanics from 1978 through 

1995 (Table 28) (NCHS, public use data tapes, 1978– 

1995). Birth cohort data from the HHANES also 

reflect recent declines in the prevalence of smoking 

among the three subgroups of Hispanics surveyed: 

Cuban Americans, Mexican Americans, and Puerto 

Ricans (Escobedo and Remington 1989). 

Between 1978 and 1995, the prevalence of smoking among Hispanic men and women decreased, although smoking prevalence was consistently greater 

among men than among women, according to the 

NHIS data (Table 28). Previous analysis of the 

HHANES birth cohort data showed that after 1970, 

the prevalence of smoking declined sharply among 

Mexican American men and less dramatically among 

Puerto Rican and Cuban American men (Escobedo et 

al. 1989a). In contrast, the prevalence of smoking 

changed little or increased among most age groups of 

Cuban American, Mexican American, and Puerto 

Rican women. For men participating in the 1982–1984 

HHANES, the smoking prevalence ranged from 41.3 

percent (among Puerto Ricans) to 43.6 percent (among 

Mexican Americans) (Escobedo and Remington 1989), 

compared with 31.6 percent of Hispanic men in the 

1983–1985 NHIS. For women participating in 

HHANES, the smoking prevalence ranged from 23.1 

percent (among Cuban Americans) to 32.6 percent 

(among Puerto Ricans) (Escobedo and Remington 

1989), compared with 20.4 percent of Hispanic women 

in the 1983–1985 NHIS. 

Several factors help explain why the HHANES 

estimates for men are at least 10 percentage points 

higher than the NHIS estimates for men for a comparable period and why the HHANES estimates 

for women also show a higher prevalence than the NHIS 

estimates for women. Most importantly, the HHANES 

was more likely to select an immigrant population than 

the NHIS because HHANES offered respondents the 

choice of English or Spanish questionnaires. In addition, the HHANES sampled Cuban Americans from 

Dade County, Florida; Mexican Americans from Arizona, California, Colorado, New Mexico, and Texas; and 

Puerto Ricans from New York, New Jersey, and Connecticut. On the other hand, the NHIS, administered 

only in English, is a national sample of the general population, which includes a wider range of racial/ethnic 

66 Chapter 2 
 

 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 28.	 Percentage of adult Hispanics who reported being current cigarette smokers,* overall and 

by gender, age, and education, National Health Interview Surveys, United States, 1978–1995 

aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 30.1 1.9 25.6 1.6 23.6 1.4 21.5 1.4 20.5 1.6 18.9 0.7 

Gender 

Men 37.6 3.0 31.6 2.9 29.6 2.3 27.8 2.3 25.9 2.6 22.9 2.4 

Women 23.3 2.0 20.4 1.9 18.4 1.5 15.9 1.6 15.5 1.9 15.1 1.7 

Age (years) 

18–34 32.3 2.7 25.8 2.2 23.6 1.9 21.1 1.9 21.0 2.4 19.8 2.2 

35–54 30.4 2.7 28.4 3.2 26.3 2.3 25.7 2.2 23.4 2.7 19.8 2.5 

>55 22.9 2.8 19.9 4.2 18.2 2.8 13.7 2.6 12.4 3.7 14.3 3.5 

Education§ 

Less than high school 33.4 3.5 28.0 2.6 26.1 2.3 22.9 2.4 21.6 2.7 20.2 2.4 

High school 25.2 3.9 28.1 3.8 27.8 3.0 27.6 2.7 24.2 3.3 21.6 3.4 

Some college 32.7 6.5 26.4 4.0 20.3 3.2 19.9 3.1 19.5 4.2 21.0 4.1 

College 17.1 6.6 20.4 6.1 13.9 3.0 16.1 3.4 13.1 3.8 8.7 3.1 

*For 1978–1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their 

lives and who reported at the time of survey that they currently smoked. For 1992–1995, current smokers 

include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of 

survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

groups and subgroups, including persons who identified themselves as Puerto Rican, Cuban, Mexican, 

Mexicano, Mexican American, Chicano, Spanish, or of 

other Latin American origin. Because Hispanics with 

higher levels of education are less likely to smoke than 

other groups of Hispanics (Haynes et al. 1990), the 

slightly different target populations in the HHANES 

and in the NHIS—which probably differ in educational 

attainment—may help explain differences in smoking 

prevalence between the two surveys. 

tern also was observed in a smaller survey of Hispanic 

adults in a semirural city near Albuquerque, New 

Mexico (Samet et al. 1992). 

Hispanics aged 55 years and older consistently 

had the lowest rates of cigarette smoking in the NHIS 

(Table 28), a finding similar to that from the HHANES 

(Haynes et al. 1990). Rates of cigarette smoking 

generally have been highest among Hispanics with a 

high school education or less and lowest among those 

who have graduated from college (Table 28). This patIn the 1982–1984 HHANES, having 12 or more 

years of education was associated with lower rates of 

cigarette smoking among Cuban American, Mexican 

American, and Puerto Rican men (Haynes et al. 1990). 

Among Hispanic women, those with 7–11 years of education had the highest rates of cigarette smoking. 

The 1982–1984 HHANES used an eight-item 

scale to measure level of acculturation in Mexican 

Americans (Delgado et al. 1990). The variables 

used to construct the scale were language ability, 

self-identification, parents’ racial/ethnic identification, 

and generation in the United States. Among Mexican 

American women, there was a dose-response 

relationship between the level of acculturation and 

Patterns of Tobacco Use 67 
 

<15–24 cigarettes 

<15–24 cigarettes 

<15–24 cigarettes 

<15–24 cigarettes 

<15–24 cigarettes 

<15–24 cigarettes 

Surgeon General's Report 

Table 29.	 Percentage of adult Hispanic smokers* who reported smoking <15, 15–24, or >25 cigarettes per 

day, overall and by gender, age, and education, National Health Interview Surveys, United States, 

1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 

<15 cigarettes 

>25 cigarettes 

56.0 4.5 55.6 4.1 58.3 3.2 64.5 3.3 72.7 3.8 65.0 4.1 

30.7 4.3 31.3 3.0 30.9 3.1 29.3 3.2 21.2 3.5 27.3 3.9 

13.3 2.4 13.2 3.0 10.9 2.1 6.2 1.4 6.2 2.0 7.7 2.0 

Gender 

Men 

<15 cigarettes 

>25 cigarettes 

52.4 5.9 52.5 5.5 54.9 4.6 62.5 4.4 71.8 5.2 62.4 5.1 

32.6 5.0 33.0 4.2 32.1 4.6 29.8 4.2 20.7 4.5 29.9 4.7 

15.0 3.6 14.4 3.9 13.0 2.9 7.7 2.1 7.6 3.0 7.6 3.7 

Women 

<15 cigarettes 

>25 cigarettes 

61.4 5.2 59.8 4.9 63.0 4.2 67.6 4.7 74.1 5.3 68.8 5.6 

27.8 5.3 28.8 5.1 29.1 4.2 28.6 4.5 22.0 5.1 23.5 5.1 

10.7 3.6 11.5 3.9 7.9 2.3 3.8 1.5 3.9 2.0 7.7 3.1 

Age (years) 

18–34 

<15 cigarettes 

>25 cigarettes

61.7 6.2 61.4 5.3 61.6 4.8 69.8 4.3 78.1 4.7 70.2 6.3 

28.5 5.5 29.2 4.5 29.3 4.8 27.8 4.1 17.3 4.2 25.1 6.1 

9.9 2.6 9.4 3.7 9.1 2.7 2.4 1.1 4.6 2.4 4.7 2.5 

35–54 

<15 cigarettes 

>25 cigarettes 

49.0 6.3 44.5 6.5 56.0 5.0 59.7 4.9 66.5 6.7 60.4 6.2 

33.4 6.7 35.1 5.0 31.7 4.7 29.6 4.6 25.2 6.1 28.6 5.9 

17.7 4.5 20.4 4.9 12.3 3.5 10.6 2.9 8.2 3.9 11.0 3.8 

>55 

<15 cigarettes 

>25 cigarettes 

49.6 8.6 61.2 9.7 50.8 7.7 55.2 9.7 69.8 13.5 56.2 11.5 

33.3 8.3 29.2 8.7 34.8 7.5 36.0 10.2 24.6 13.1 32.9 10.5 

17.1 7.6 9.6 5.8 14.4 5.9 8.5 5.5 5.6 4.5 10.9 7.0 

*For 1978–1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their 

lives and who reported at the time of survey that they currently smoked. For 1992–1995, current smokers 

include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of 

survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data 

were combined. 

‡

95% confidence interval. 

age-adjusted (to the 1980 U.S. population) cigarette 

smoking prevalence; 19 percent of Mexican-oriented 

women and 28 percent of U.S.-oriented women were 

current cigarette smokers (Haynes et al. 1990). The 

unadjusted prevalence of cigarette smoking among U.S. 

women aged 18 years and older in 1983 was 29.5 percent (CDC 1994c). No clear relationship was observed 

among Mexican American men (Haynes et al. 1990). 

Navarro (1996) used data from the 1990 California Tobacco Survey to study level of acculturation in 

Hispanics (most of whom were of Mexican origin). 

Level of acculturation was defined based on the language spoken in the home: persons from Englishspeaking homes were classified as having a high level 

of acculturation, and persons from Spanish-speaking 

homes were classified as having a low level of 

68 Chapter 2 
 

<

<

<

<

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 29. Continued 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Education§ 

Less than high school 

<15 cigarettes 55.4 5.0 54.1 5.3 59.2 5.1 66.2 5.2 71.1 6.6 63.5 7.2 

15–24 cigarettes 29.9 5.6 33.7 5.9 30.3 4.7 27.6 5.1 23.1 6.1 30.0 7.2 

>25 cigarettes 14.7 4.3 12.3 4.7 10.5 3.3 6.2 2.3 5.8 3.6 6.5 3.4 

High school 

<15 cigarettes 53.4 9.9 53.9 7.5 53.9 6.6 60.9 6.0 70.5 7.2 61.3 7.3 

15–24 cigarettes 34.7 9.4 33.2 7.1 32.5 6.6 32.6 5.7 25.4 7.0 28.7 6.6 

>25 cigarettes 11.9 5.9 12.9 4.4 13.6 4.5 6.5 2.6 4.2 3.0 10.1 4.4 

Some college 

<15 cigarettes 50.6 10.3 50.5 11.8 54.1 9.2 55.1 8.6 70.8 9.7 55.5 9.9 

15–24 cigarettes 37.3 10.8 24.1 9.6 31.9 8.2 35.1 8.4 21.0 8.9 36.1 10.1 

>25 cigarettes 12.2 7.5 25.5 9.9 14.0 6.4 9.8 5.3 8.2 5.1 8.4 5.1 

College 

<15 cigarettes 55.6 22.1 50.0 17.1 55.3 11.7 64.4 11.3 75.8 11.7 71.6 15.7 

15–24 cigarettes 17.8 15.2 36.4 13.5 29.6 10.6 27.1 10.3 16.7 10.3 17.9 12.8 

>25 cigarettes 26.7 21.7 13.6 10.1 15.0 9.3 8.5 5.9 7.5 6.3 10.5 10.7 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

acculturation. The data were analyzed by gender and 

for three levels of educational attainment (<12, 12, and 

>12 years). Among men, smoking prevalence varied 

for those with <12 and 12 years of education; smoking 

prevalence was highest among whites, intermediate 

among Hispanics of high acculturation, and lowest 

among Hispanics of low acculturation. This pattern 

also existed for women, but in all three of the education categories. Additionally, in a multivariate analysis that controlled for age, gender, educational 

attainment, and Mexican origin, Hispanics with a low 

acculturation level were significantly less likely to 

smoke than those with a high acculturation level. 

Navarro suggested that level of acculturation may be 

related to the degree of urbanization of the person’s 

or family’s residence in the country of origin. For example, persons living in rural areas of Latin America 

appear to be less likely to smoke than those living in 

urban areas (USDHHS 1992). The relationship between cigarette smoking and level of acculturation 

among Hispanics living in the United States may 

be confounded by adaptation to industrial and 

urban societies (Navarro 1996), especially if persons 

or families from rural areas acculturate more slowly 

than those from urban areas. Future research into this 

topic might ideally include information on the person’s 

or family’s residence in the country of origin. 

Number of Cigarettes Smoked Daily 

Between 1978 and 1985, trends in the number of 

cigarettes smoked per day by Hispanic smokers remained stable (Table 29) (NCHS, public use data tapes, 

1978–1995). More recently, however, an increasing proportion of Hispanic smokers have been smoking fewer 

than 15 cigarettes per day, and a declining proportion 

of them have been smoking 25 or more cigarettes per 

day. For example, in 1978–1980, 13.3 percent of Hispanic smokers smoked 25 or more cigarettes per day. 

By 1994–1995, this proportion was 7.7 percent. 

From 1978 to 1993, Hispanic men were more 

likely than Hispanic women to smoke 25 or more cigarettes per day, although these differences were not statistically significant (Table 29). Consumption patterns 

in 1994–1995 were similar across genders. Between 

1978 and 1995, the prevalence of smoking 25 or more 

cigarettes per day declined among Hispanics at all 

levels of education (Table 29), although only the 

decline among persons with less than a high school 

education was statistically significant. 

Patterns of Tobacco Use 69 
 

 

Surgeon General's Report 

Quitting Behavior 

In the NHIS, the prevalence of smoking cessation among Hispanic smokers increased moderately 

between 1978 and 1995 (Table 30) (NCHS, public use 

data tapes, 1978–1995). No notable differences in 

smoking cessation between Hispanic men and women 

were observed. The prevalence of cessation was higher 

among persons in the older age groups and among 

college graduates (Table 30). 

Data from a recent multivariate analysis of the 

1991 NHIS (CDC 1993) indicate that after the analysis 

controlled for gender, age, education, and poverty status, Hispanics were more likely than whites to stop 

smoking for at least one day during the previous year. 

Hispanics who had stopped smoking for at least one 

day were about as likely as whites to have stopped for 

at least one month. Overall, Hispanic smokers were 

slightly more likely than whites to have quit smoking 

for at least one month. 

Data from the NCI Supplement of the 1992–1993 

CPS indicate that among Hispanics aged 18 years and 

older who were daily smokers one year before the survey, 59.8 percent reported that they were still smoking 

daily and that they had not tried quitting for at least 

one day during the previous year (Table 4). Another 

28.5 percent had tried quitting for at least one day, 5.6 

percent were occasional smokers (i.e., smoked only on 

some days), 2.5 percent had not smoked for the past 

1–90 days, and 3.6 percent had not smoked for the past 

91–364 days. This distribution was similar to that 

among whites, with the exception that slightly more 

Hispanics had become occasional smokers. 

Table 30. Percentage of adult Hispanic ever smokers who have quit,* overall and by gender, age, and 

education, National Health Interview Surveys, United States, 1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 35.0 2.8 39.3 2.8 42.8 2.4 44.1 2.6 44.2 3.1 46.2 3.2 

Gender 

Men 35.5 3.4 40.5 4.1 43.0 3.3 43.0 3.6 45.8 4.1 48.2 4.3 

Women 34.2 4.3 37.6 4.3 42.5 3.4 45.6 3.5 41.6 4.5 43.1 4.5 

Age (years) 

18–34 27.9 4.2 32.6 3.2 33.7 3.6 34.3 3.5 31.4 4.3 32.5 4.9 

35–54 37.2 3.9 39.2 5.2 44.9 3.7 45.3 3.6 46.4 4.7 49.6 4.9 

>55 51.0 5.5 57.2 7.6 60.4 5.0 67.1 5.6 70.3 6.9 68.1 6.4 

Education§ 

Less than high school 30.5 3.6 37.7 4.0 43.3 3.6 45.5 4.4 42.8 5.0 47.6 5.1 

High school 45.7 7.1 40.0 6.0 41.2 4.6 41.9 4.4 44.2 6.0 44.5 6.2 

Some college 38.5 9.8 47.8 6.9 55.0 6.3 52.6 6.1 52.8 8.8 49.1 7.6 

College 59.4 14.2 52.2 10.3 59.2 7.2 56.6 7.3 64.0 8.9 71.1 9.1 

*The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are 

persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that 

they were not smoking, and ever smokers include current and former smokers. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

70 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Women of Reproductive Age 

From 1978 to 1995, a large proportion of Hispanic 

women of reproductive age (18–44 years) have smoked 

cigarettes, although this proportion has been declining 

over time (Table 31) (NCHS, public use data tapes, 

1978–1995). Some evidence suggests that the prevalence 

of smoking among women of reproductive age varies 

according to the country of origin, with Cuban American women (22.6 percent) and Mexican American 

women (23.2 percent) reporting cigarette smoking in 

lower proportions than Puerto Rican women (33.5 percent) (Pletsch 1991). In a comparison of data from the 

HHANES and the National Health and Nutrition Examination Survey (NHANES), Guendelman and 

Abrams (1994) found that Mexican American women 

of reproductive age were less likely than their white 

counterparts to smoke cigarettes at each of the reproductive stages (interconception, pregnancy, lactation, 

and postpartum). 

The National Survey of Family Growth collected 

data in 1982 and 1988 on the smoking behavior of 

females 15–44 years of age during their most recent 

pregnancy. In 1982, 17.2 percent of Hispanic women 

reported smoking during their most recent pregnancy, 

compared with 13.7 percent in 1988 (Pamuk and 

Mosher 1992; Chandra 1995). More recent data from 

U.S. final natality statistics indicate that smoking rates 

for Hispanics during pregnancy declined from 8 percent in 1989 to 4.3 percent in 1995 (Table 6). Hispanic 

adolescent mothers were about as likely as older 

Hispanic mothers to have smoked (USDHHS 1994). 

Hispanic mothers report generally low rates of 

tobacco use, ranging from 1.8 to 4.1 percent for Mexican, Cuban, Central American, and South American 

mothers to 8.2 to 10.4 percent for Puerto Rican and 

“other” Hispanic mothers and those of unknown 

Hispanic origin (Table 6). Ventura and colleagues 

(1995) reported that 3 percent of foreign-born or Puerto 

Table 31.	 Percentage of Hispanic women of reproductive age who reported being current cigarette 

smokers,* overall and by education, National Health Interview Surveys, United States, 

1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total	 25.5 2.7 22.2 2.2 19.8 1.7 16.7 1.8 17.3 2.3 16.4 2.0 

Education§ 

Less than high school 29.2 4.3 24.4 4.4 23.5 4.0 17.6 3.7 17.0 4.4 17.0 3.7 

High school 21.3 5.6 27.6 5.3 24.1 3.7 21.4 3.6 25.1 5.3 21.4 4.7 

Some college 12.9 7.5 21.5 6.7 15.9 4.6 19.5 4.2 17.0 6.1 16.5 5.3 

College 17.3 12.0 16.7 8.3 12.7 4.7 15.2 5.0 12.9 5.8 5.1 4.1 

*For 1978–1991, current cigarette smokers include women aged 18–44 years who reported smoking at least 100 

cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992–1995, 

current smokers include women aged 18–44 years who reported smoking at least 100 cigarettes in their lives 

and who reported at the time of survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

Patterns of Tobacco Use 71 
 

Surgeon General's Report 

Rican-born Hispanic mothers smoked, compared with 

9 percent of their United States-born counterparts 

(Ventura et al. 1995). Data on tobacco use among these 

mothers may be skewed because California and New 

York do not report this information, and together these 

states account for almost half of all Hispanic births 

(Ventura et al. 1996). 

The National Pregnancy and Health Survey, conducted between October 1992 and August 1993 and 

sponsored by NIDA, provides nationally representative data on the prevalence of prenatal drug use among 

Hispanic females of reproductive age (15–44 years). 

According to National Pregnancy and Health Survey 

data, 5.8 percent of Hispanic women reported using 

cigarettes during their pregnancies (NIDA 1994). In 

the 1985 and 1990 NHISs, questions related to smoking were asked of women aged 18–44 years who had 

given birth within the past five years. In 1985, 16.8 

percent of Hispanic women smoked during the 12 

months before the birth and 10.3 percent smoked after 

learning of their pregnancy; in 1990, 12.1 percent 

smoked during the year before birth and 8 percent after learning of their pregnancy (Floyd et al. 1993). 

Young People 

Cigarette Smoking 

Despite the dearth of information on tobacco use 

among Hispanic youths, several studies have been able 

to identify trends in smoking initiation and patterns 

of tobacco use by analyzing data from the HHANES, 

the MTF surveys of high school seniors (Figure 3), and 

small local surveys (for example, Smith et al. 1991; 

Dusenbury et al. 1992; Vega et al. 1993). 

HHANES data have shown that smoking initiation increased rapidly among Cuban Americans, Mexican Americans, and Puerto Ricans between ages 11 and 

15 years, peaked between ages 15 and 19 years, and 

declined after the age of 20 years (Escobedo et al. 1990). 

In all age groups, smoking initiation rates were higher 

among males than among females. 

of smoking initiation, whereas those with more than 

a high school education had slightly lower smoking 

initiation rates. Because educational attainment is a 

reliable (Liberatos et al. 1988) although limited (Montgomery and Carter-Pokras 1993) indicator of socioeconomic status, these data suggest that an association 

between smoking initiation and socioeconomic status 

may exist among Hispanics, as it does for the general 

U.S. population. However, these differences in smoking initiation by educational attainment were not as 

large as those found among whites. 

Slight variations in smoking initiation by level 

of education were found when the HHANES data were 

combined for all three Hispanic subgroups (although 

these were three separate surveys, it was necessary 

to combine three groups to estimate trends for all 

three groups). Hispanics with less than a high school 

education had the highest rates of smoking initiation, 

with an earlier age of onset and a more accelerated 

rate of smoking initiation during young adolescence, 

than Hispanics with more years of schooling. Hispanics with a high school education had intermediate rates 

In addition, data from the 1994–1995 (combined) 

NHSDAs indicate that among persons aged 30–39 

years, Hispanic men and women were less likely to 

become daily smokers than whites (Table 11) 

(USDHHS, Substance Abuse and Mental Health Services Administration, public use data tapes, 1994– 

1995). Among persons in this age group who had ever 

smoked daily, the initiation patterns among Hispanics were more like those of African Americans than 

those of whites. The average ages for first trying a 

cigarette and for becoming a daily smoker were about 

one year higher for Hispanic men than for white men 

and about two years higher for Hispanic women than 

for white women (Table 11). 

Among high school seniors who participated in 

the MTF in 1985–1989, 23.8 percent of Mexican American males, 22.0 percent of Puerto Rican and Latino 

males, 18.7 percent of Mexican American females, and 

24.7 percent of Puerto Rican and Latina females 

smoked cigarettes in the previous month (Bachman et 

al. 1991b). In addition, 11.6 percent of Mexican American males, 13.3 percent of Puerto Rican and Latino 

males, 8.1 percent of Mexican American females, and 

13.3 percent of Puerto Rican and Latina females 

smoked cigarettes daily in the previous month. The 

prevalence of smoking one-half pack of cigarettes or 

more per day was somewhat higher among males 

(5 to 6 percent) than among females (2 to 4 percent). 

Between 1976 and 1989, the prevalence of daily 

smoking declined among Mexican American high 

school seniors of both genders and among Puerto 

Rican and Latina females, according to the MTF 

data (Bachman et al. 1991b). Decreases occurred between 1976 and 1984 among Mexican American males 

and between 1980 and 1989 among Puerto Rican and 

Latina females. Among Mexican American females, 

decreases in the prevalence of daily smoking occurred 

between 1976 and 1984, and no decline was observed 

in more recent years. In contrast, little change in the 

prevalence of daily smoking was observed among 

Puerto Rican and Latino males over the entire survey 

period (Bachman et al. 1991b). 

72 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Recent data indicate that rates of smoking are 

generally lower among Hispanic youths than among 

white youths. The 1989 TAPS showed that 11.8 percent of Hispanics reported some level of cigarette 

smoking, compared with 17.7 percent of whites and 

6.2 percent of African Americans (Moss et al. 1992). 

However, patterns may differ for migrant and resident 

youths. In a recent study of 214 migrant Hispanic adolescents enrolled in school in San Diego, the prevalence 

of cigarette smoking within the 30 days preceding the 

survey increased by school grade, from a low of 

10 percent of 9th graders to 14 percent of 10th graders, 

21 percent of 11th graders, and 18 percent of 12th 

graders (Lovato et al. 1994). Also, acculturation may 

influence smoking behavior. In a study of sixth and 

seventh graders in Dade County, Florida, Vega and colleagues (1993) found that cigarette smoking was more 

frequent among United States-born Cuban American 

children (23.8 percent) than among foreign-born 

Cuban Americans (15.1 percent). 

According to the 1995 YRBS, 34.0 percent of Hispanic high school students and 38.3 percent of white 

high school students smoked on one or more days 

during the previous month (CDC 1996). Hispanic students were significantly more likely than African 

American students (19.2 percent) to have smoked during the previous month. Regarding more frequent 

smoking, Hispanic youths (10.0 percent) and African 

American youths (4.5 percent) were less likely than 

white youths (19.5 percent) to have smoked on at least 

20 days during the previous month. 

Lowry and colleagues (1996) analyzed crosssectional data on 6,321 adolescents (aged 12–17 years) 

from the YRBS supplement to the 1992 NHIS. Hispanics were significantly less likely than whites to have 

smoked in the previous 30 days. This analysis controlled statistically for the educational level of the responsible adult, for family income, for the age and 

gender of the adolescent, and for whether the adolescent was in or out of school. In an analysis comparing 

measured carbon monoxide from expired air with selfreported smoking among a sample of seventh- through 

tenth-grade New York State public school students, 

Wills and Cleary (1997) found that the self-report sensitivity was slightly lower for Hispanics than for whites 

but that the magnitude of the effect was small. When 

self-reported smoking rates were adjusted for carbon 

monoxide values, ninth- and tenth-grade Hispanic 

students had significantly lower smoking prevalences 

than whites. 

Recent findings from focus groups conducted at 

several U.S. sites suggest that Hispanic parents may 

be more likely than white parents to express clear antismoking messages and that smoking by Hispanic adolescents may be a sign of disrespect toward parents 

(Mermelstein et al. 1996). 

According to the 1996 MTF surveys, the prevalence of previous-month smoking (estimated by combining 1995 and 1996 data) among Hispanic high school 

seniors (25.4 percent) was intermediate to that among 

African American seniors (14.2 percent) and white seniors (38.1 percent) (Institute for Social Research, University of Michigan, unpublished data from the 1996 

MTF surveys). A similar pattern was observed for tenthgrade students: previous-month smoking prevalences 

were 23.7 percent for Hispanics, 32.9 percent for whites, 

and 12.2 percent for African Americans. However, 

among eighth-grade students, the Hispanic-white 

difference was attenuated: 19.6 percent of Hispanics, 

22.7 percent of whites, and 9.6 percent of African Americans were previous-month smokers. Trends in daily 

smoking among high school seniors show that rates for 

Hispanics have been consistently lower than for whites 

since 1977 and higher than for African Americans since 

the early 1980s (Figure 3). 

The MTF surveys suggest that rates of smoking 

among Hispanics have increased in the 1990s. The 

prevalence of previous-month smoking (based on twoyear rolling averages) among eighth-grade students 

was 16.7 percent in 1992 and 19.6 percent in 1996; 

among tenth-grade students, the prevalence was 18.3 

percent in 1992 and 23.7 percent in 1996; and among 

high school seniors, the prevalence was 21.7 percent 

in 1990 and 25.4 percent in 1996 (Johnston et al. 1996; 

Institute for Social Research, University of Michigan, 

unpublished data from the 1996 MTF surveys). Similarly, YRBS data indicate that the prevalence of previous-month smoking among Hispanic high school 

students was 25.3 percent in 1991 (USDHHS 1994) and 

34.0 percent in 1995 (CDC 1996). 

Other Risk Behaviors 

Using data from the YRBS supplement to the 1992 

NHIS, Escobedo and colleagues (1997) observed associations (USDHHS 1994) between cigarette smoking 

among Hispanic adolescents and specific behaviors compromising to health. Marijuana use, binge drinking, and 

weapon carrying were significantly associated with cigarette smoking among Hispanic adolescent males; marijuana use, binge drinking, multiple sexual partners, and 

physical fighting were associated with cigarette use 

among Hispanic adolescent females. The analysis 

controlled statistically for age, ethnicity, gender, parental educational level, region of the country, and other risk 

behaviors. 

Patterns of Tobacco Use 73 
 

Surgeon General's Report 

Smokeless Tobacco Use 

Recent trends in smokeless tobacco use among 

Hispanic adolescents have changed little. According 

to the MTF surveys, previous-month smokeless 

tobacco use (based on two-year rolling averages) 

was reported by 4.2 percent of eighth-grade Hispanic 

students in 1992 and 5.2 percent in 1996; among 

tenth-grade students, the prevalence was 6.2 percent in 1992 and 4.0 percent in 1996; and among high 

school seniors, the prevalence was 4.4 percent in 1987 

and 8.1 percent in 1996 (Johnston et al. 1996; 

Institute for Social Research, University of Michigan, 

unpublished data from the 1996 MTF surveys). YRBS 

data indicate that the prevalence of previous-month 

use among Hispanic high school students was 5.5 percent in 1991 (USDHHS 1994) and 4.4 percent in 1995 

(CDC 1996). 

Hispanic adolescent males are much less likely 

than white adolescent males to use smokeless tobacco. 

Among male high school students participating in the 

1995 YRBS, for example, 5.8 percent of Hispanics and 

25.1 percent of whites had used smokeless tobacco 

during the previous month (CDC 1996). Prevalence 

among females was 3.1 percent for Hispanics and 2.5 

percent for whites. 

Retrospective Analyses of Smoking Prevalence Among 

African Americans and Hispanics 

Because of the lack of long-term national survey 

data on smoking behavior among racial/ethnic groups, 

retrospective analysis is the only way to reconstruct 

smoking prevalences for African Americans before 

1965 and for Hispanics before 1978. The retrospective 

method of constructing smoking prevalences for successive birth cohorts of men and women in the U.S. 

population was first reported by Harris (USDHEW 

1979; Harris 1983). Harris’s methodology later served 

as the basis for a report in which smoking prevalences 

were presented for Cuban American, Mexican American, and Puerto Rican men and women (Escobedo 

and Remington 1989). Most recently, the NCI (1991) 

published some results of an analysis of birth cohorts 

of whites and African Americans. Another type of retrospective analysis has also been used to estimate longterm trends in cigarette smoking. This approach has 

been the basis of two published reports, one that presented smoking trends among Hispanics in various age 

groups (Escobedo et al. 1989a) and another that presented smoking trends among Hispanic young adults 

(Escobedo et al. 1989b). For this section of the report, 

both types of retrospective analysis were used to generate information not previously available. 

Prevalence of Cigarette Smoking Among 

Successive Birth Cohorts 

The following detailed analysis of smoking 

trends over time—according to gender and educational 

attainment of defined birth cohorts (based on the year 

of birth)—uses data from the 1987 NHIS (for African 

Americans) and the 1982–1984 HHANES (for Hispanics). The smoking histories of respondents were constructed according to the ages they reported cigarette 

smoking initiation and cessation. Information about these 

two smoking-related events was then used to classify 

each respondent as a nonsmoker, current smoker, or 

former smoker from birth to interview and to calculate 

the proportion of people smoking each year in each birth 

cohort. (See Appendix 5 for a discussion of the validation of this methodology.) The resulting birth cohort 

curves (Figures 7–10) represent smoking prevalences of 

each cohort for each year from birth to interview 

(throughout childhood, adolescence, and adulthood) 

(NCHS, public use data tapes, 1978, 1979, 1980, 1982– 

1984, and 1987 and 1988 combined). By comparing the 

curves among successive birth cohorts, one can examine 

smoking trends over time for those cohorts. 

African Americans 

The prevalence of smoking among successive 

birth cohorts of African American men with at least a 

high school education has declined gradually, with the 

peak and age-specific smoking prevalences for the 

most recent cohort (1958–1967) being lower than the 

prevalences for previous cohorts’ curves (Figure 4). 

In contrast, little progress has been made in reducing the prevalence of cigarette smoking among 

74 Chapter 2 
 

 

High school 

education 

Percentage 

80 

70 

60 

50 

40 

30 

20 

10 

0 

1910 1920 1930 1940 1950 1960 1970 1980 

Less than a high 

school education 

Percentage 

80 

70 

60 

50 

40 

30 

20 

10 

0 

1910 1920 1930 1940 1950 1960 1970 1980 

Year Year 

Birth cohorts: 

1908–1917 1918–1927 1928–1937 1938–1947 1948–1957 1958–1967 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

successive birth cohorts of African American men with 

less than a high school education (Figure 7). Although 

smoking prevalences declined slightly for successive 

cohorts, the peak prevalence for the most recent cohort continues to be nearly as high as that for previous cohorts. In addition, smoking prevalences during 

adolescence among African Americans with less than 

a high school education did not decrease between successive birth cohorts. 

Despite initial increases in smoking prevalence 

among successive birth cohorts of African American 

women with at least a high school education, 

prevalences have declined in recent years (Figure 8). 

The declines in prevalence among African American 

women with at least a high school education are not 

as marked as the declines observed among successive 

birth cohorts of African American men of a similar 

educational background. Smoking prevalences among 

African American women with less than a high school 

education have increased markedly, with the most 

recent cohort (1958–1967) showing the highest peak 

(Figure 8). 

Hispanics 

Among six successive birth cohorts of Hispanic 

men with at least a high school education covering the 

years 1908–1967, the peak prevalence of smoking increased gradually for the first three cohorts but declined 

beginning with the 1938–1947 cohort (Figure 9). In addition, the rate of increase in smoking prevalence during adolescence slowed markedly for the most recent 

cohort compared with rates for previous cohorts. 

The smoking prevalence pattern among successive birth cohorts of Hispanic men with less than a 

high school education (Figure 9) is similar to the pattern among African American men with a similar educational background. Smoking prevalences have 

declined slightly since the early 1950s, when the highest prevalence was observed for the 1918–1927 cohort. 

The slight decline in smoking prevalence among 

successive birth cohorts of Hispanic women with at 

least a high school education is similar to the decline 

among African American women with a similar educational background (Figure 10). However, the decline 

Figure 7. Cigarette smoking prevalence among successive birth cohorts of African American men, by 

education, National Health Interview Surveys, United States, 1978–1980, 1987, and 1988* 

*Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth 

to interview, they provide information about the smoking prevalence of each cohort during childhood, 

adolescence, and adulthood. 

Sources: National Center for Health Statistics, public use data tapes, 1978–1980, 1987 (Cancer Control 

Supplement and Epidemiology Supplement), and 1988; Escobedo and Peddicord 1996. 

Patterns of Tobacco Use 75 
 

 

High school 

education 

Percentage 

80 

70 

60 

50 

40 

30 

20 

10 

0 

1910 1920 1930 1940 1950 1960 1970 1980 

Year 

1910 1920 1930 1940 1950 1960 1970 1980 

0 

10 

20 

30 

40 

50 

60 

70 

80 

Percentage 

Less than a high 

school education 

Year 

Birth cohorts: 

1908–1917 1918–1927 1928–1937 1938–1947 1948–1957 1958–1967 

Surgeon General's Report 

among Hispanic women began more recently, with the 

1938–1947 cohort. The peak prevalence for the most 

recent cohort of Hispanic females with at least a high 

school education was similar to the peak prevalence 

for African American women of the same educational 

level (25 percent). 

The smoking prevalences among successive birth 

cohorts of Hispanic women with less than a high school 

education increased slightly over time and then leveled off (Figure 10). In addition, the prevalence of 

smoking during adolescence increased much more 

rapidly in the most recent birth cohort than in previous cohorts. However, the overall pattern of smoking 

prevalence in this subgroup of Hispanic women does 

not show the dramatic increases observed in successive birth cohorts of African American women with a 

similar educational background. The peak prevalence 

for the most recent birth cohort of Hispanic women 

with less than a high school education (34 percent) was 

substantially lower than the peak prevalence for the 

corresponding cohort of African American women (54 

percent). 

The slight changes in smoking prevalences 

among successive birth cohorts of Hispanic women, 

regardless of educational background, may be the result of the larger proportion of Mexican American 

women who compose these subgroups. Although 

few changes have been observed in the prevalence 

of smoking among successive birth cohorts of Mexican American women, in recent birth cohorts of 

Cuban American and Puerto Rican women, more 

women have smoked cigarettes than those in previous cohorts (Escobedo and Remington 1989). Had 

more Cuban American and Puerto Rican women been 

included in the HHANES, the pattern may well have 

been different. 

The results of these birth cohort analyses show 

that educational attainment is the most powerful predictor of temporal trends in smoking prevalence. In 

both racial/ethnic groups, men, and to a lesser extent 

women, with at least a high school education have 

made progress in reducing cigarette smoking. However, men with less than a high school education, regardless of race/ethnicity, are as likely to smoke now 

as they were in previous decades. Recent cohorts of 

African American women with less than a high school 

education are now substantially more likely to smoke 

than their counterparts in previous decades. 

Figure 8. Cigarette smoking prevalence among successive birth cohorts of African American women, by 

education, National Health Interview Surveys, United States, 1978–1980, 1987, and 1988* 

*Because these birth cohort curves are the result of calculations of smoking prevalence for each year from 

birth to interview, they provide information about the smoking prevalence of each cohort during childhood, 

adolescence, and adulthood. 

Sources: National Center for Health Statistics, public use data tapes, 1978–1980, 1987 (Cancer Control 

Supplement and Epidemiology Supplement), and 1988; Escobedo and Peddicord 1996. 

76 Chapter 2 
 

 

80 80 

70 70 

60 60 

50 50 

40 

age 

40

ent

0 

10 

20 

30 

0 

10 

20 

Perc

30 

High school 

education 

1910 1920 1930 1940 1950 1960 1970 1980 

Less than a 

high school 

education 

1910 1920 1930 1940 1950 1960 1970 1980 

Year Year

Birth cohorts: 

1908–1917 1918–1927 1928–1937 1938–1947 1948–1957 1958–1967 

Percentage 

30 

40 

50 

60 

70 

80 80
 

70
 

High school 

education 

1910 1920 1930 

0 

10 

20 

1940 1950 1960 1970 1980 1910 1920 1930 1940 1950 1960 1970 1980 

0 

10 

20 

1908–1917 

Birth cohorts: 

Year 

1918–1927 1928–1937 1938–1947 

Year 

1948–1957 1958–1967 

Less than a high 

school education 

60 

Percentage

Percentage 50
 

40
 

30
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Figure 9. 	 Cigarette smoking prevalence among successive birth cohorts of Hispanic men, by education, 

Hispanic Health and Nutrition Examination Survey, 1982–1984* 

*Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth 

to interview, they provide information about the smoking prevalence of each cohort during childhood, 

adolescence, and adulthood. 

Sources: National Center for Health Statistics, public use data tapes, 1982–1984; Escobedo and Peddicord 1996. 

Figure 10. Cigarette smoking prevalence among successive birth cohorts of Hispanic women, by education, 

Hispanic Health and Nutrition Examination Survey, 1982–1984* 

*Because these birth cohort curves are the result of calculations of smoking prevalence for each year from birth 

to interview, they provide information about the smoking prevalence of each cohort during childhood, 

adolescence, and adulthood. 

Sources: National Center for Health Statistics, public use data tapes, 1982–1984; Escobedo and Peddicord 1996. 

Patterns of Tobacco Use 77 
 Percentage 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Men with less 

than a high 

school education 

Men with a high 

school education 

Women with less 

than a high 

school education 

Women with a 

high school 

education 

1910 1920 1930 1940 1950 1960 1970 1980 1990 

Year 

Surgeon General's Report 

Long-Term Trends in Cigarette-Smoking 

Initiation 

Another type of birth cohort analysis was conducted to determine long-term trends in smoking among 

young adults (20–29 years of age) by gender and educational attainment. Information on smoking history was 

determined during the years that each person was 20–29 

years of age. For each year, the prevalence of smoking 

was determined by dividing the number of smokers aged 

20–29 years by the total number of persons aged 20–29 

years in that year. Unlike the birth cohort analysis described in the preceding section of this chapter, in this 

analysis the group for which prevalences are computed 

changes from year to year because new respondents enter the group when they are 20 years old and leave it 

when they become 30 years old. 

The information for African Americans was obtained from NHIS data collected in 1978, 1979, 1980, 

1987, and 1988, whereas the information for Hispanics was obtained from HHANES data collected in 

1982–1984. 

African Americans 

Up until the early 1970s, African American men 

had substantially higher rates of smoking initiation 

than African American women (Figure 11). Within 

each gender group, significant education-related 

differences were not observed until the 1950s, when 

rates of smoking initiation among male high school 

graduates began to decline sharply and rates among 

females with less than a high school education began 

to increase. Rates among less educated females surged 

dramatically between 1970 and 1980. After 1980, rates 

of smoking have consistently declined among each of 

these subgroups of African Americans except males 

with less than a high school education. 

Hispanics 

Significant education-related differences in 

rates of smoking initiation have been evident only 

among Hispanic males. Around 1940, Hispanic males 

who graduated from high school began showing 

Figure 11. Reconstructed prevalence of smoking among African American adults aged 20–29 years, by 

gender and education, National Health Interview Surveys, United States, 1910–1988 

Source: National Center for Health Statistics, public use data tapes, 1978, 1979, 1980, 1987, and 1988 combined. 

78 Chapter 2 
 

Percentage 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Men with less 

than a high 

school education 

Men with a high 

school education 

Women with less 

than a high 

school education 

Women with a 

high school 

education 

1920 1930 1940 1950 1960 1970 1980 1990 

Year 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

appreciably lower smoking rates than Hispanic males 

with less than a high school education (Figure 12). 

These differences increased in the 1960s and even more 

rapidly in the mid-1970s. No consistent differences 

in smoking rates by education were observed among 

Hispanic females. 

Cigarette Brand Preferences 

Knowing what influences cigarette brand preference among smokers is believed to be important because this information can be used to develop 

counteradvertising strategies. In the late 1970s and the 

1980s, the 12 most commonly used brands of cigarettes—Marlboro, Winston, Salem, Kool, Pall Mall, Kent, 

Benson & Hedges, Camel, Merit, Vantage, Virginia 

Slims, and Newport—were used by at least 76 percent 

of all current U.S. smokers, according to data from the 

1986 Adult Use of Tobacco Survey (AUTS) and the 1978– 

1980 and 1987 NHISs (Table 32). Brand use varied somewhat by race/ethnicity. For example, the top brands 

preferred by African Americans were Kool, Newport, 

Salem, and Winston, whereas whites preferred 

Marlboro, Winston, Salem, and Benson & Hedges. 

These differences in part reflect the greater use 

of mentholated cigarettes by African Americans 

(Cummings et al. 1987; USDHHS 1989). Fifty-five 

percent of all African American smokers reported using one of three brands that were available only in 

mentholated form (Newport, Kool, and Salem). Similar patterns and percentages of brand preferences were 

observed in the 1987 NHIS (Table 32). 

Hymowitz and colleagues (1995) recently studied menthol cigarette smoking among adults who participated in a stop-smoking study. Among African 

Americans who smoked menthol cigarettes (n = 174), 

the top reasons given for smoking menthols were as 

follows: 83 percent said that menthol cigarettes tasted 

better than nonmenthol cigarettes, 63 percent said that 

they had always smoked menthol cigarettes, 52 percent said that menthol cigarettes were less harsh to the 

throat than nonmenthol cigarettes, 48 percent found 

inhalation to be easier with menthol cigarettes, and 33 

Figure 12. Reconstructed prevalence of smoking among Hispanic adults aged 20–29 years, by gender 

and education, Hispanic Health and Nutrition Examination Surveys, 1920–1984 

Source: National Center for Health Statistics, public use data tapes, 1982–1984. 

Patterns of Tobacco Use 79 
 

Surgeon General's Report 

Table 32.	 Percentage of self-reported cigarette brand use among adult current cigarette smokers, overall 

and by race/ethnicity and gender, National Health Interview Surveys (NHIS) 1978–1980 combined, Adult Use of Tobacco Survey (AUTS) 1986, and NHIS 1987 

Benson & 

Hedges 

% ±CI‡

Camel 

 % ±CI

Kent 

 % ±CI

Kool 

 % ±CI

Marlboro

 % ±CI 

Sample 

Survey Size* 

NHIS 1978–1980 

African Americans 

Total

Men

Women

 1,540 6.0 1.6 1.3 0.7 1.6 0.6 28.0 4.0 3.8 1.3 

 750 4.0 1.7 2.3 1.2 1.1 0.8 31.3 4.7 4.2 1.7 

 790 8.1 2.4 0.3 0.4 2.2 0.8 24.4 4.5 3.3 1.6 

Whites 

Total 

Men

Women

13,228 4.2 0.6 4.4 0.5 4.8 0.5 6.3 0.6 17.5 1.1 

6,675 2.7 0.5 6.9 0.7 4.0 0.6 6.8 0.8 20.3 1.5 

6,553 5.8 0.8 1.7 0.4 5.7 0.6 5.8 0.7 14.4 1.2 

AUTS 1986 

African Americans 

Total

Men

Women

 388 9.2 3.5 0.9 1.2 0.6 0.6 19.9 4.9 6.7 3.1 

 176 4.6 3.8 1.2 2.0 0.5 0.5 19.6 7.2 10.2 5.5 

212 13.8 5.7 0.5 1.2 0.7 0.7 20.3 6.7 3.2 2.9 

Whites 

Total 

Men 

Women 

3,693 4.1 0.8 4.9 0.9 2.7 2.7 4.2 0.8 28.3 1.8 

1,883 2.9 0.9 7.9 1.5 2.3 2.3 4.7 1.2 32.4 2.6 

1,810 5.5 1.3 1.5 0.7 3.2 3.2 3.5 1.0 23.7 2.4 

NHIS 1987 

African Americans 

Total

Men

Women

 428 6.3 2.7 2.6 2.0 2.5 2.3 24.8 5.4 2.7 1.5 

 174 2.2 1.8 3.4 3.3 2.1 2.8 30.3 8.6 3.1 2.2 

 254 11.2 5.1 1.7 2.2 3.0 3.7 18.4 5.5 2.3 1.9 

Whites 

Total

Men

Women

 1,860 5.8 1.2 3.8 1.1 3.1 0.9 3.7 1.0 31.1 2.6 

934 3.8 1.4 5.7 1.6 2.1 1.0 3.6 1.3 38.8 3.5 

926 8.1 2.1 1.6 1.7 4.3 1.6 3.7 1.4 22.0 3.1 

*Unweighted sample size. 

†

In the NHIS, “other” includes other brands, no particular brand, and roll-your-own cigarettes; in the AUTS, 

“other” includes other brands. 

percent said that they could inhale menthol cigarettes always smoked menthol cigarettes, and 21 percent found 

more deeply. Among a small sample (n = 39) of whites inhalation to be easier with menthol cigarettes. 

who smoked menthol cigarettes, 74 percent said that Evaluating changes in young smokers’ brand 

menthol cigarettes tasted better than nonmenthol ciga- preferences is especially important because it can 

rettes, 51 percent said that menthol cigarettes were more help identify factors that influence their choices and 

soothing to the throat, 39 percent said that they had may suggest ways to discourage them from starting 

80 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Merit 

% ±CI

Newport

 % ±CI

Pall

 Mall

 % ±CI

 Salem

 % ±CI

 Vantage

 % ±CI

 Virginia 

Slims

 % ±CI

 Winston

 % ±CI 

Other† 

% ±CI 

1.4 

1.3 

1.4 

0.6 

0.9 

0.9 

5.2 

5.6 

4.7 

2.3 

2.7 

2.8 

6.9 

9.6 

4.0 

1.5 

2.5 

1.3 

15.9 

12.7 

19.4 

2.0 

2.8 

2.7 

0.9 

0.7 

1.1 

0.5 

0.2 

0.8 

2.6 

0.2 

5.2 

0.9 

0.3 

1.9 

11.9 

13.4 

10.3 

2.1 

3.3 

2.1 

14.5 

13.6 

15.6 

2.0 

2.5 

3.2 

4.3 

4.0 

4.7 

0.4 

0.6 

0.6 

1.2 

1.2 

1.2 

0.4 

0.4 

0.4 

5.4 

6.4 

4.2 

0.4 

0.6 

0.5 

9.0 

7.9 

10.3 

0.7 

0.8 

1.0 

3.5 

3.5 

3.5 

0.4 

0.6 

0.5 

2.2 

0.2 

4.4 

0.3 

0.1 

0.5 

13.3 

15.5 

10.8 

0.9 

1.2 

1.0 

23.9 

20.6 

27.5 

1.1 

1.4 

1.4 

0.1 

0.0 

0.1 

0.4 

0.0 

0.5 

23.4 

26.2 

20.5 

5.2 

8.0 

6.7 

2.3 

2.8 

1.8 

1.8 

3.0 

2.2 

17.4 

15.2 

19.7 

4.6 

6.5 

6.6 

0.4 

0.5 

0.4 

0.8 

1.3 

1.0 

3.4 

0.3 

6.4 

2.2 

1.0 

4.0 

6.5 

8.8 

4.2 

3.0 

5.1 

3.3 

9.4 

10.2 

8.5 

3.6 

5.5 

4.6 

4.9 

4.6 

5.3 

0.9 

1.2 

1.3 

2.4 

2.7 

2.1 

0.6 

0.9 

0.8 

3.5 

3.9 

2.9 

0.7 

1.1 

0.9 

8.2 

6.4 

10.4 

1.1 

1.4 

1.7 

3.6 

3.5 

3.8 

0.7 

1.0 

1.1 

3.0 

0.4 

6.0 

0.7 

0.4 

1.3 

11.0 

13.0 

8.8 

1.2 

1.9 

1.6 

19.2 

15.4 

23.6 

1.6 

2.0 

2.4 

1.3 

0.8 

1.9 

1.1 

1.2 

2.0 

19.6 

21.9 

16.9 

5.7 

9.1 

5.3 

2.2 

2.1 

2.3 

1.2 

1.6 

1.7 

12.7 

11.9 

13.5 

3.8 

5.4 

4.7 

0.5 

0.0 

1.0 

0.5 

0.0 

1.2 

1.9 

0.5 

3.4 

1.2 

0.8 

2.4 

11.7 

12.9 

10.3 

4.0 

6.3 

4.8 

11.2 

8.8 

14.1 

3.5 

4.4 

5.0 

4.5 

4.1 

4.9 

1.0 

1.4 

1.3 

2.8 

2.5 

3.2 

0.9 

1.2 

1.3 

2.5 

3.2 

1.5 

0.8 

1.2 

0.8 

7.0 

5.4 

8.9 

1.4 

1.9 

2.1 

2.6 

2.8 

2.4 

0.8 

1.0 

1.1 

3.8 

0.1 

8.2 

0.9 

0.2 

2.0 

12.3 

13.6 

10.7 

1.9 

2.7 

2.6 

17.0 

14.3 

20.5 

1.9 

2.5 

2.8 

‡

95% confidence interval.
 

Sources: National Center for Health Statistics, public use data tapes, 1978–1980 and 1987; Centers for Disease
 

Control, public use data tapes, 1986.
 

to smoke (Hunter et al. 1986; Pierce et al. 1991a). Data 

from the 1989 TAPS show that among adolescents who 

usually bought their own cigarettes (61.9 percent), 

Marlboro was the most popular brand among whites 

(71.4 percent) and Hispanics (60.9 percent), and the 

mentholated brands of Newport (61.3 percent), Kool 

(10.9 percent), and Salem (9.7 percent) were preferred 

by African Americans (Table 33) (CDC 1992d). In the 

1993 TAPS, the most popular brands were still 

Marlboro among whites (63.5 percent) and Hispanics 

(45.4 percent) and Newport among African Americans 

(70.4 percent) (Table 33). 

Patterns of Tobacco Use 81 
82 Chapter 2 

 African American 

 African American 

 African American 

Surgeon General's Report 

Table 33.	 Percentage of self-reported cigarette brand use among adolescent current cigarette smokers,* by 

race/ethnicity, Teenage Attitudes and Practices Surveys (TAPSs), 1989 and 1993 

Benson & 

Hedges

_________ 

% ±CI‡

Sample 

Size† Survey 

Camel _________ 

% ±CI

Kool ________ 

% ±CI

Marlboro 

_________ 

% ±CI

Merit _________ 

% ±CI

Newport 

________ 

% ±CI 

TAPS 1989 

Race 

African American 41 3.3 6.4 3.1 6.2 10.9 9.1 8.7 9.7 0.0 0.0 61.3 15.7 

White 807 1.3 1.2 8.4 2.2 0.6 0.5 71.4 3.4 0.5 0.5 5.6 1.6 

Ethnicity

 Hispanic 46 3.7 4.9 7.6 8.6 5.8 6.1 60.9 15.0 0.0 0.0 12.8 9.5

Non-Hispanic 817 1.3 1.2 8.1 2.1 0.8 0.6 69.1 3.5 0.5 0.5 8.0 1.9 

TAPS-II 1993 

Race 

41 1.7 3.3 0.0 0.0 11.9 10.9 8.5 8.5 § § 70.4 14.1

White 646 0.2 0.4 14.4 3.1 0.5 0.8 63.5 4.3 NA NA 8.7 2.4 

Ethnicity

 Hispanic 50 0.0 0.0 10.1 7.7 4.5 8.6 45.4 14.9 NA NA 34.0 15.1

Non-Hispanic 647 0.3 0.4 13.6 3.1 0.9 0.8 60.9 4.3 NA NA 11.0 2.5 

Salem _________

% ±CI

Sample 

Size† Survey 

TAPS 1989 

Race 

41 9.7 7.2 0.0 0.0 NA NA 0.0 0.0 2.9 5.8

White 807 1.0 0.7 0.1 0.2 NA NA 3.4 1.3 7.6 2.0 

Vantage 

_________ 

% ±CI

Virginia 

Slims ________ 

% ±CI

Winston 

_________ 

% ±CI

Other _________ 

% ±CI 

Ethnicity

 Hispanic 46 2.8 5.4 0.0 0.0 NA NA 0.0 0.0 6.5 7.6

Non-Hispanic 817 1.5 0.8 0.1 0.2 NA NA 3.3 1.3 7.3 1.9 

TAPS-II 1993 

Race 

41 1.4 2.7 NA NA 0.5 1.0 0.0 0.0 5.5 6.0

White 646 1.0 0.8 NA NA 1.0 1.0 1.2 0.1 9.4 2.8 

Ethnicity

 Hispanic 50 0.0 0.0 NA NA 0.0 0.0 6.0 8.1 0.0 0.0

Non-Hispanic 647 1.1 0.8 NA NA 1.1 1.0 0.8 0.7 10.4 2.9 

*Current smokers are adolescents aged 12–18 years who reported smoking cigarettes on 1 or more of the 30 days 

preceding the survey. 

†

Unweighted sample size.

‡

95% confidence interval.
 

§

Numbers are too small for meaningful analysis; this brand is included in the “other” category.
 

NA = data not available.
 

Sources: National Center for Health Statistics, public use data tapes, 1989; Centers for Disease Control and
 

Prevention, public use data tapes, 1993.
 
 

1

 Let βi0 = logistic regression coefficient for the ith ethnicity 

group before education was included, and βi1 = logistic regression 

coefficient for the ith ethnicity group after education was 

included. Then βi0 - βi1 measures education’s confounding effect 

on the relationship between smoking and ethnicity. The variance 

of βi0 - βi1 can be approximated as var(βi0) + var(βi1); and the

standard error, SE(βi0 - βi1), is the square root of the variance. In 

terms of the more commonly used measure, odds ratio (OR), the 

following relationship exists: ORi0/ORi1 = exp(βi0 - βi1). The 95

percent confidence interval for ORi0/ORi1 can then be computed 

as exp[(βi0 - βi1) ± 1.96 X SE(βi0 - βi1)]. Education’s confounding

effect on the relationship between smoking and ethnicity is 

determined to be statistically significant if the 95 percent 

confidence interval for ORi0/ORi1 does not include 1.0. 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

A notable change in brand preferences occurred 

between 1989 and 1993, however. The percentage of 

adolescents purchasing Marlboro cigarettes decreased 

13 percent, whereas the percentage of those purchasing Camel cigarettes increased 64 percent and the 

percentage of those purchasing Newport cigarettes 

increased 55 percent (CDC 1994a). The declining preference for Marlboro cigarettes was greatest among 

Hispanics (CDC 1992d). Increases in brand preference 

were greatest among white adolescents who preferred 

Camel cigarettes and among Hispanic adolescents who 

preferred Newport cigarettes. In 1993, the brands of 

cigarettes most commonly smoked among a small 

sample of Vietnamese middle and high school students 

in Worcester, Massachusetts, were Marlboro (71.0 percent) and Camel (9.7 percent) (Wiecha 1996). 

Data from the 1989 and 1993 TAPSs indicate that 

brand preference is more concentrated among adolescents than among adults. In both surveys, the three 

most popular brands for each racial/ethnic group were 

purchased by at least 80 percent of adolescent smokers. Both surveys identified very small numbers of 

smokers among African American adolescents (41 in 

1989 and 45 in 1993) and Hispanic adolescents (46 in 

1989 and 50 in 1993); thus, brand preference estimates 

for these groups are imprecise. 

Effects of Education and Race/Ethnicity on Cigarette-Smoking Behavior
 

In this chapter, smoking prevalence has been 

shown to vary by racial/ethnic minority group and 

by educational attainment. Because educational attainment varies among racial/ethnic groups and is 

related to smoking prevalence, the question arises as 

to whether racial/ethnic differences in smoking can 

be explained by differences in educational attainment. 

A previous analysis of the 1985 NHIS data 

showed that controlling for selected measures of socioeconomic status, such as employment status and 

poverty level, reduced differences in the smoking 

prevalence between African Americans and whites 

(Novotny et al. 1988). 

Although education, together with such variables 

as income and occupation, is often used to create a 

composite measure of socioeconomic status, many 

researchers have used education as a single proxy indicator of socioeconomic status because education is 

often associated with many lifestyle characteristics 

(Liberatos et al. 1988). In addition, education data are 

usually more accurate and easier to collect than income 

and occupation data (Liberatos et al. 1988). 

for 1987, 1988, 1990, and 1991 (Table 34) (NCHS, public use data tapes, 1987, 1988, 1990, and 1991). The 

multivariable logistic regression technique was used 

to assess the odds ratios of smoking behaviors for 

African Americans, American Indians and Alaska 

Natives, Asian Americans and Pacific Islanders, and 

Hispanics compared with whites, before and after adjusting for the effects of educational attainment.1 Four 

separate logistic regression models were constructed 

for different measures of smoking behavior: current 

smoking, ever smoking, heavy smoking (among current smokers), and smoking cessation (among ever 

smokers). Four design variables were created to represent the racial/ethnic groups (African Americans, 

American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics), with whites 

serving as the reference group. Similarly, two design 

Findings in this report indicate that the 

prevalences of cigarette smoking, smoking cessation, 

and heavy smoking are all associated with race/ 

ethnicity and educational attainment. Because racial/ 

ethnic group and educational attainment are often interrelated, multivariable models were used in this 

analysis to distinguish how each variable influences 

smoking behavior. Data were derived from the NHISs 

Patterns of Tobacco Use 83 
 

 

 

 

 

 _

 *Includes persons aged 25 years and older.

 †Education was evaluated at three levels: less than high school education, high school education, and at least
 

some college.


 ‡OR0 = odds ratio not controlling for education; OR1 = odds ratio controlling for education. Odds ratios were 

calculated as follows: OR i0/ORi1 = exp(βi0 - βi1), where βi0 is the logistic regression coefficient for the ith ethnic 

group before controlling for education, and βi1 is the coefficient after controlling for education. Other variables 

in the logistic models include age, gender, marital status, geographic region, and year of survey.

 §95% confidence interval. 

 ΔCurrent cigarette smokers are persons who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked. The association presented is for current smoking 

compared with former and never smoking.

 ¶Former smokers are those who reported smoking at least 100 cigarettes in their lives and who reported at the
 

time of survey that they were not smoking cigarettes. The association presented is for former smoking
 

compared with current smoking.
 

**Heavy smokers include current smokers who reported at the time of survey that they were smoking 25 or more 

cigarettes per day. The association presented is for heavy smoking compared with current smoking of 1–24 

cigarettes per day. 

††Ever smokers are those who reported at the time of survey that they had smoked at least 100 cigarettes in their 

lives, regardless of their current smoking status. The association presented is for ever smoking compared with 

never smoking. 

Sources: National Center for Health Statistics, public use data tapes, 1987, 1988, 1990, and 1991; Escobedo 

et al. 1995. 

Surgeon General's Report 

Table 34.	 Relationship between smoking status and race/ethnicity among adults,* before and after 

controlling for education,† National Health Interview Surveys, United States, 1987, 1988, 1990, and 

1991 aggregate data 

Not controlling 

for education _________________

OR ‡

0 CI§ 

Controlling 

for education ________________

OR1 CI 

Effect of 

education‡ 

_________________ 

OR0/OR1 CI Smoking status	 Race/ethnicity 

CurrentΔ	 African Americans 1.11 1.06, 1.16 0.96 0.91, 1.00 1.16 1.08, 1.24 

Hispanics 0.74 0.70, 0.79 0.58 0.54, 0.62 1.29 1.18, 1.42 

Asian Americans and Pacific Islanders 0.51 0.45, 0.58 0.54 0.47, 0.62 0.94 0.78, 1.14 

American Indians and Alaska Natives 1.46 1.16, 1.85 1.20 0.95, 1.51 1.22 0.88, 1.70 

Whites 1.0 referent 1.0 referent 1.0 referent 

Former¶	 African Americans 0.65 0.61, 0.70 0.74 0.69, 0.78 0.89 0.81, 0.97 

Hispanics 0.97 0.90, 1.05 1.16 1.07, 1.26 0.84 0.75, 0.94 

Asian Americans and Pacific Islanders 0.95 0.80, 1.13 0.88 0.74, 1.05 1.08 0.85, 1.38 

American Indians and Alaska Natives 0.66 0.47, 0.92 0.74 0.53, 1.02 0.89 0.56, 1.41 

Whites 1.0 referent 1.0 referent 1.0 referent 

Heavy**	 African Americans 0.19 0.16, 0.21 0.18 0.16, 0.20 1.04 0.87, 1.25 

Hispanics 0.25 0.21, 0.30 0.23 0.20, 0.28 1.08 0.84, 1.38 

Asian Americans and Pacific Islanders 0.17 0.11, 0.26 0.17 0.11, 0.27 0.97 0.52, 1.83 

American Indians and Alaska Natives 0.74 0.58, 0.95 0.70 0.55, 0.90 1.05 0.74, 1.49 

Whites 1.0 referent 1.0 referent 1.0 referent 

Ever††	 African Americans 0.82 0.79, 0.86 0.76 0.72, 0.79 1.09 1.02, 1.16 

Hispanics 0.63 0.60, 0.67 0.55 0.52, 0.58 1.15 1.06, 1.24 

Asian Americans and Pacific Islanders 0.39 0.35, 0.43 0.40 0.36, 0.44 0.97 0.83, 1.13 

American Indians and Alaska Natives 1.21 1.05, 1.40 1.09 0.93, 1.27 1.11 0.90, 1.38 

Whites 1.0 referent 1.0 referent 1.0 referent 

84 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

variables were created to represent persons with and 

without a high school education, with persons having 

at least some college education serving as the reference group. In addition to including race/ethnicity 

and education, the logistic regression models included 

the year of the survey, age, gender, marital status, and 

geographic region. 

Education was first omitted from and then entered in these models. The difference in estimated coefficients before and after the inclusion of education 

was computed for each of the four design variables 

representing the different racial/ethnic groups. The 

variance of this difference was estimated to be the sum 

of the variances of the two coefficients. The 95 percent confidence interval of the difference was computed by using this variance estimate. The difference 

in coefficients was translated into the ratio of the odds 

ratios before and after adjusting for education (Table 

34) (Escobedo et al. 1995). 

Current Smoking 

Before adjustment for education, the data indicated that African Americans as well as American 

Indians and Alaska Natives were more likely than 

whites to be current smokers (Table 34). Hispanics as 

well as Asian Americans and Pacific Islanders were 

substantially less likely than whites to be current smokers. After adjustment for the confounding effects of 

education, the odds ratios for current smoking among 

African Americans and Hispanics decreased significantly (Table 34). 

Thus, when the data were adjusted for education, current smoking among African Americans 

did not differ from whites—an indication that 

the differences in the unadjusted rates were probably 

attributable to factors related to differences in educational attainment. For Hispanics, current smoking 

was lower than for whites, and adjustment for the 

confounding effects of education further accentuated 

these differences. 

Smoking Cessation 

African Americans as well as American Indians 

and Alaska Natives who had ever smoked were substantially less likely than whites to have quit smoking 

(Table 34). When education was included in these 

models, the odds ratio for smoking cessation increased, 

suggesting that lack of education accounts for some 

but not all of the low rates of quitting in these two 

groups. Before adjustment for education, the data 

showed that Hispanics were as likely as whites to quit 

smoking. However, after adjustment for education, 

the data showed that Hispanics were more likely than 

whites to quit smoking. Thus, the unadjusted smoking cessation rate was lower among both African 

Americans and Hispanics than among whites partially 

because of confounding by educational attainment. A 

similar magnitude of change was observed among 

American Indians and Alaska Natives, but this difference was not statistically significant. Educational attainment does not explain why African Americans are 

less likely than whites to quit smoking. 

Heavy Smoking 

Members of all four racial/ethnic groups were 

less likely than whites to be heavy smokers, before and 

after the data were adjusted for the effects of education (Table 34). These differences were greatest 

between whites and Asian Americans and Pacific Islanders and were smallest between whites and American Indians and Alaska Natives. Because the odds ratio 

of heavy smoking changed little after adjustment for 

education, the differences in heavy smoking between 

racial/ethnic groups appear to be independent of 

factors associated with educational attainment. 

Ever Smoking 

Before the data were adjusted for the effects 

of education, all racial/ethnic groups except American Indians and Alaska Natives were substantially less 

likely than whites to have ever smoked (Table 34). 

After adjustment for education, the odds ratios for ever 

smoking among African Americans and Hispanics declined even further, and these declines were statistically significant. This finding suggests that if African 

Americans and Hispanics had socioeconomic status 

more comparable with that of whites, they would be 

even less likely ever to smoke than whites. 

Differences in current smoking, quitting, and ever 

smoking between whites and Asian Americans and 

Pacific Islanders also were found. Asian Americans 

and Pacific Islanders were less likely than whites to be 

current smokers, substantially less likely to be ever 

smokers, but also slightly less likely to have quit smoking. After adjustment for education, the odds ratios 

associated with these smoking behaviors changed little 

(Table 34). Thus, the lower smoking prevalences 

among Asian Americans and Pacific Islanders may be 

related to factors other than education—presumably 

cultural factors associated with being an Asian American or a Pacific Islander in the United States. 

Patterns of Tobacco Use 85 
 

Surgeon General's Report 

Occasional Smoking 

In addition to smoking more cigarettes each day, 

whites who currently smoke are generally more likely 

than members of other racial/ethnic groups to smoke 

on a daily basis. According to the 1993, 1994, and 1995 

combined NHISs, 15.2 percent of whites who smoked 

were occasional (i.e., nondaily) smokers, compared 

with 26.0 percent of African Americans, 22.2 percent 

of American Indians and Alaska Natives, 33.1 percent 

of Asian Americans and Pacific Islanders, and 35.5 percent of Hispanics. Only the estimate for American Indians and Alaska Natives did not differ significantly 

from that for whites (data not shown) (NCHS, public 

use data tapes, 1993, 1994, 1995). Husten and 

colleagues (1998) used data from the 1991 NHIS to 

study persons who had ever smoked 100 lifetime cigarettes but who had never smoked on a daily basis. 

Among the ever smokers, African Americans (12.0 

percent), American Indians and Alaska Natives (15.0 

percent), Asian Americans and Pacific Islanders (12.1 

percent), and Hispanics (16.8 percent) were all significantly more likely than whites (6.2 percent) never to 

have smoked daily. In gender-specific multivariate 

analyses that controlled for income, age, and education, African Americans, Hispanics, and others (American Indians and Alaska Natives combined with Asian 

Americans and Pacific Islanders) were significantly 

more likely never to have smoked daily. 

Exposure to Environmental Tobacco Smoke
 

Data on exposure to environmental tobacco 

smoke (ETS) among members of U.S. racial/ethnic 

minority groups are extremely limited. In the 1991– 

1993 NHIS, nearly one-third of all respondents indicated exposure to ETS at home three or more days per 

week (Table 35) (NCHS, public use data tapes, 1991– 

1993). African Americans (37.6 percent) and American Indians and Alaska Natives (36.9 percent) were 

more likely than other groups to report such levels of 

exposure to ETS at home. These findings are consistent with smoking prevalence data presented earlier 

in this chapter. Similar patterns exist among nonsmokers, although the occurrence of higher levels of exposure (three or more days) is reduced by 40 to 60 percent among nonsmokers compared with the total 

population. Among Asian American, Pacific Islander, 

American Indian, and Alaska Native nonsmokers, 

women had substantially more prolonged exposure 

than men. 

Using 1988–1991 NHANES III data on persons 

aged 17 years and older who did not use tobacco, Pirkle 

and colleagues (1996) found that 36.9 percent of African Americans, 35.1 percent of Mexican Americans, 

and 37.4 percent of whites reported that they were 

exposed to ETS either at home or at work. Wagenknecht and colleagues (1993) analyzed data collected 

in 1985 and 1986 from 3,300 persons aged 18–30 years 

who were recruited in four urban centers (Birmingham, Chicago, Minneapolis, and Oakland). African 

Americans were more likely than whites to report 

home exposure to ETS and to report that they spent 

time mostly with smokers. Using 1988 NHIS data on 

the number of smokers in the home, Overpeck and Moss 

(1991) estimated that 42.4 percent of U.S. children aged 

five years and younger were living in a household with 

a smoker. In 1988, African American children were more 

likely to be living with a smoker (51.3 percent) than were 

white children (41.6 percent), and non-Hispanic children (43.2 percent) were more likely to be doing so than 

were Hispanic children (35.8 percent). 

In recent years, small-scale studies have reported 

on potential exposure to ETS among young people in 

U.S. racial/ethnic groups. For example, in two rural 

Alaska villages, an analysis of saliva samples from children in the Alaska Native Head Start program showed 

that 44 percent of the children (3–6 years of age) had 

cotinine concentrations indicative of exposure to ETS 

(Etzel et al. 1992). Recent research has compared levels 

of cotinine (a metabolite of nicotine) in biological fluids and hair of children, young adults, and adults 

(Pattishall et al. 1985; Wagenknecht et al. 1993; Crawford 

et al. 1994; Knight et al. 1996; Pirkle et al. 1996). Most 

of these investigations (Pattishall et al. 1985; Crawford 

et al. 1994; Knight et al. 1996; Pirkle et al. 1996) reported 

that African Americans who did not use tobacco had 

higher cotinine levels than whites, even after ETS 

exposure and other factors were taken into account. 

Further factors, including possible racial differences in 

nicotine absorption and metabolism (Pattishall et al. 

1985; Benowitz et al. 1995; Clark et al. 1996; Knight et 

al. 1996) and measurement issues, need to be considered (see Racial/Ethnic Differences in Nicotine Metabolites in Chapter 3 for further discussion of this topic). 

86 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 35.	 Percentage of all adults and nonsmokers who reported levels of exposure to environmental 

tobacco smoke in the home, by race/ethnicity and gender, National Health Interview Surveys, 

United States, 1991–1993 aggregate data 

exposure* 

Home 

African 

Americans 

% +CI† 

Asian Americans/ 

Pacific Islanders 

% +CI

American Indians/ 

Alaska Natives 

% +CI 

Hispanics 

% +CI 

Whites 

% +CI Total (%)‡ 

All adults 

0–2 days 

Total 

Men 

Women 

60.8 1.3 78.5 2.8 60.9 4.5 74.4 1.7 66.9 0.6 67.1 

57.3 2.0 76.7 3.7 67.3 6.4 72.6 2.3 66.1 0.7 66.1 

63.5 1.5 80.4 3.9 54.9 5.6 76.0 2.1 67.5 0.7 68.0 

>3 days 

Total 

Men 

Women 

37.6 0.7 20.5 2.9 36.9 4.4 24.5 1.6 31.9 0.6 31.7 

41.1 2.0 21.9 3.7 30.8 6.1 26.3 2.2 32.7 0.7 32.7 

34.8 1.5 19.0 3.8 42.7 5.9 22.7 2.1 31.3 0.7 30.8 

Nonsmokers 

0–2 days 

Total 

Men 

Women 

80.4 1.3 87.6 2.5 84.6 4.5 86.6 1.4 85.7 0.5 85.3 

80.1 2.1 92.0 2.8 90.0 4.9 87.2 2.0 85.2 0.7 85.1 

80.6 1.5 84.0 3.7 78.8 7.0 86.1 1.9 86.2 0.6 85.4 

>3 days 

Total 

Men 

Women 

18.3 1.2 11.7 2.5 13.5 4.3 12.6 1.4 13.5 0.5 13.9 

18.6 2.0 7.0 2.7 9.5 4.8 12.0 1.9 14.0 0.7 14.0 

15.1 1.5 15.5 3.6 17.8 6.4 13.0 2.0 13.1 0.6 13.8 

*Home exposure was the average number of days per week that anyone was inside the home, as reported by 

respondents answering “yes” to the question, “Does anyone smoke cigarettes, cigars, or pipes anywhere inside 

this home?” However, these percentages include persons who indicated no exposure. Percentages exclude 

“don’t know” and “not ascertained” responses regarding the number of days; therefore, the sum may not 

total 100%. 

†

95% confidence interval. 

‡

Total includes persons of other, unknown, or multiple ethnicities and unknown Hispanic origin. 

Source: National Center for Health Statistics, public use data tapes, 1991–1993. 

Comparisons Between Racial/Ethnic Minority Groups in Current Tobacco Use 

Cigarette Smoking 

The most recent data from the 1994 and 1995 combined NHISs show that the age-adjusted prevalence 

of current cigarette smoking was highest among 

American Indians and Alaska Natives (36.0 percent), 

intermediate among African Americans (26.5 percent) 

and whites (26.4 percent), and lowest among Hispanics (18.0 percent) and Asian Americans and Pacific Islanders (14.2 percent) (Table 36) (NCHS, public use 

data tapes, 1994–1995). Among all racial/ethnic groups 

except American Indians and Alaska Natives, men had 

significantly higher rates of cigarette smoking than 

women. Using data from the NCI Supplement of the 

1992–1993 CPS, Shopland and colleagues (1996) reported patterns similar to those seen in the NHIS for 

African Americans, Asian Americans and Pacific Islanders, Hispanics, and whites (data on American Indians and Alaska Natives were not included in their 

report). From 1978 through 1995, the age-adjusted 

Patterns of Tobacco Use 87 
African

Americans

American

Indians and

Alaska Natives

Asian

Americans

and Pacific

Islanders

Hispanics

Whites

70 

60 

50 

40 

30 

20 

10 

0 

Percentage 

1978–80	 1983–85 1987–88 1990–91 1992–93 1994–95
 

African 

Americans 

American 

Indians and 

Alaska Natives 

Asian 

Americans 

and Pacific 

Islanders 

Hispanics 

Whites 

Year 

 

Surgeon General's Report 

prevalence of smoking declined for African Americans, in prevalence was observed, particularly among men,
 

Asian Americans and Pacific Islanders, and Hispanics— for American Indians and Alaska Natives from 1978–
 

overall and for both men and women (Figures 13–15) 1980 to 1983–1985, prevalence did not change overall
 

(NCHS, public use data tapes, 1978–1995). A differ- or for men from 1983–1985 to 1994–1995 or for women
 

ent picture emerges for American Indians and from 1978–1980 to 1994–1995.
 

Alaska Natives. Although a fairly substantial decline
 

Table 36.	 Age-adjusted prevalence of current cigarette smoking* among adults, overall and by race/ 

ethnicity and gender, National Health Interview Surveys, United States, 1994 and 1995 

aggregate data 

African 

Americans ____________ 

% ±CI† 

American Indians/ 

Alaska Natives _________________ 

% ±CI 

Asian Americans/ 

Pacific Islanders _________________ 

% ±CI 

Hispanics 

__________ 

% ±CI 

Whites ___________ 

Characteristic % ±CI 

Total 26.5 1.7 36.0 6.0 14.2 2.7 18.0 1.5 26.4 0.7 

Men 31.4 2.6 39.3 9.5 23.8 5.1 21.7 2.3 28.1 1.0 

Women 22.2 1.8 32.9 8.0 5.4 2.1 14.6 1.8 25.0 0.9 

*Current cigarette smokers are persons who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked every day or on some days. Data were age-adjusted 

to the 1990 U.S. census population.

†

95% confidence interval.
 

Source: National Center for Health Statistics, public use data tapes, 1994–1995.
 

Figure 13.	 Trends in the age-adjusted prevalence of current cigarette smoking among African American, 

American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and white 

adults, National Health Interview Surveys, United States, 1978–1995 aggregate data 

Note: Data were age-adjusted to the 1990 U.S. census population.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

88 Chapter 2 
African

Americans

American

Indians and

Alaska Natives

Asian

Americans and

Pacific

Islanders

Hispanics

Whites

70 

60 African 

Americans 

50 

American 

1978–80 1983–85 1987–88 1990–91 1992–93 1994–95 

Year 

Percentage

40 

30 

20 

10 

0 

Indians and 

Alaska Natives 

Asian 

Americans 

and Pacific 

Islanders 

Hispanics 

Whites 

African

Americans

American

Indians and

Alaska Natives

Asian

Americans and

Pacific

Islanders

Hispanics

Whites

70 

60 African 

Americans 

50 

American 

1978–80 1983–85 1987–88 1990–91 1992–93 1994–95 

Year 

Percentage 40 

30 

20 

10 

0 

Indians and 

Alaska Natives 

Asian 

Americans 

and Pacific 

Islanders 

Hispanics 

Whites 

Patterns of Tobacco Use 89 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Figure 14.	 Trends in the age-adjusted prevalence of current cigarette smoking among African American, 

American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and 

white men, National Health Interview Surveys, United States, 1978–1995 aggregate data 

Note: Data were age-adjusted to the 1990 U.S. census population.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

Figure 15. Trends in the age-adjusted prevalence of current cigarette smoking among African American, 

American Indian and Alaska Native, Asian American and Pacific Islander, Hispanic, and 

white women, National Health Interview Surveys, United States, 1978–1995 aggregate data 

Note: Data were age-adjusted to the 1990 U.S. census population.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 
 

<

<

<

Surgeon General's Report 

Table 37.	 Cigarette smoking status*† and number of cigarettes smoked per day‡ among adults, overall 

and by race/ethnicity and gender, National Health Interview Surveys, United States, 1987, 

1988, 1990, and 1991 aggregate data 

African American Indians/ Asian Americans/ 

Characteristic Americans Alaska Natives Pacific Islanders 

Total 

Never smokers 54.6 41.1 70.6 

Former smokers 15.4 21.9 13.4 

Current smokers 30.1 37.1 16.0 

Cigarettes smoked per day 

<15 cigarettes 59.6 39.7 58.1 

15–24 cigarettes 32.4 40.4 35.3 

≥25 cigarettes 8.0 19.9 6.5 

Men 

Never smokers 44.6 36.1 56.8 

Former smokers 19.6 26.0 19.6 

Current smokers 35.9 38.0 23.6 

Cigarettes smoked per day 

<15 cigarettes 54.1 27.5 56.1 

15–24 cigarettes 36.3 49.7 37.8 

≥25 cigarettes 9.6 22.8 6.1 

Women 

Never smokers 62.6 46.0 85.3 

Former smokers 12.0 17.9 6.9 

Current smokers 25.4 36.2 7.8 

Cigarettes smoked per day 

<15 cigarettes 65.8 52.3 64.6 

15–24 cigarettes 27.9 30.9 27.6 

≥25 cigarettes 6.3 16.8 7.9 

Note: For racial/ethnic-specific data on cigars, pipes, chewing tobacco, snuff, or any form of tobacco, see Table 38. 

*Never smokers are those who reported that they had never smoked at least 100 cigarettes; former smokers are 

those who reported smoking at least 100 cigarettes in their lives but who reported at the time of survey that 

they did not currently smoke; and current smokers are persons who reported smoking at least 100 cigarettes in 

their lives and who reported at the time of survey that they currently smoked. 

†

95% confidence intervals for cigarette smoking status do not exceed ±0.6% for whites, ±1.4% for African 

Americans, ±3.1% for Asian Americans and Pacific Islanders, ±6.6% for American Indians and Alaska Natives, 

±0.5% for all non-Hispanics, ±1.7% for all Hispanics, ±2.3% for Mexican Americans, ±5.2% for Puerto Ricans, 

±6.5% for Cuban Americans, ±3.3% for other Hispanics, and ±0.5% for the total population. 

Analyses of aggregated NHIS data from the 1987, Pacific Islanders (16.0 percent). The prevalence of 

1988, 1990, and 1991 surveys indicate differing patterns never smoking cigarettes was highest among Asian 

in the prevalence of current smoking, never smoking, Americans and Pacific Islanders (70.6 percent) and 

former smoking, and cigarette consumption among lowest among American Indians and Alaska Natives 

members of the four racial/ethnic groups (Table 37) (41.1 percent). Rates of former cigarette smoking were 

(NCHS, public use data tapes, 1987, 1988, 1990, and highest among whites (26.0 percent) and lowest among 

1991). The prevalence of current cigarette smoking was Asian Americans and Pacific Islanders (13.4 percent). 

highest among American Indians and Alaska Natives Overall, men were more likely than women to be cur­

(37.1 percent) and lowest among Asian Americans and rent or former smokers, whereas women were more 

90 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Hispanics 

All 

Hispanics 

Cuban 

Americans 

Puerto 

Ricans 

Mexican 

Americans 

Other 

Hispanics Whites Total§ 

60.3 

17.2 

22.5 

61.9 

17.5 

20.7 

58.7 

16.3 

25.0 

61.0 

16.8 

22.2 

59.3 

18.4 

22.4 

46.7 

26.0 

27.3 

49.2 

23.8 

27.0 

61.4 

30.0 

8.6 

43.3 

40.1 

16.6 

52.2 

36.7 

11.1 

68.4 

25.7 

5.9 

57.9 

44.8 

10.1 

26.8 

32.0 

28.3 

33.4 

42.3 

24.3 

49.8 

21.6 

28.6 

49.6 

24.1 

26.3 

52.4 

19.4 

28.3 

48.9 

22.1 

29.0 

50.6 

20.8 

28.6 

38.9 

32.1 

29.1 

40.7 

29.6 

29.6 

58.8 

30.9 

10.3 

38.5 

39.9 

21.6 

52.1 

31.7 

16.2 

65.9 

27.2 

6.9 

52.4 

35.7 

11.9 

21.7 

42.9 

35.4 

29.1 

41.2 

29.7 

69.5 

13.4 

17.0 

71.1 

12.5 

16.4 

63.3 

14.0 

22.7 

72.7 

11.7 

15.5 

66.5 

16.3 

17.2 

53.9 

20.4 

21.7 

56.8 

18.6 

24.6 

65.2 

28.8 

6.0 

49.2 

40.4 

10.5 

52.3 

41.1 

6.6 

72.8 

23.2 

4.0 

65.9 

26.6 

17.5 

32.1 

46.9 

21.1 

38.1 

43.5 

18.4 

‡

95% confidence intervals for the number of cigarettes smoked daily do not exceed ±0.8% for whites, ±2.2% for 

African Americans, ±9.7% for Asian Americans and Pacific Islanders, ±10.4% for American Indians and Alaska 

Natives, ±0.9% for all non-Hispanics, ±3.4% for all Hispanics, ±4.7% for Mexican Americans, ±8.6% for Puerto 

Ricans, ±12.4% for Cuban Americans, ±6.8% for other Hispanics, and ±0.8% for the total population. §

Includes persons of other, unknown, or multiple ethnicities and of unknown Hispanic origin. 

Source: Centers for Disease Control and Prevention 1994c. 

likely than men never to have smoked. Among African Americans, Asian Americans and Pacific Islanders, and all Hispanics except Cuban Americans, the 

majority of current smokers reported smoking fewer 

than 15 cigarettes per day, whereas whites, American 

Indians and Alaska Natives, and Cuban Americans 

were more likely than others to report smoking 25 or 

more cigarettes per day. For all groups except Puerto 

Ricans, women were much more likely than men to 

report smoking fewer than 15 cigarettes per day. 

Pipe and Cigar Use 

The prevalence of current pipe or cigar use has 

been higher among American Indians and Alaska Natives than among other racial/ethnic groups, according to aggregated data from the 1987 and 1991 NHISs 

(Table 38) (NCHS, public use data tapes, 1987 and 

1991). Current pipe or cigar use occurred primarily 

among men; use was negligible among women of all

racial/ethnic groups. The prevalence of cigar or pipe 

Patterns of Tobacco Use 91 
 

Surgeon General's Report 

Table 38.	 Percentage of adults who reported using cigars, pipes, chewing tobacco, snuff, or any form of 

tobacco, overall and by race/ethnicity and gender, National Health Interview Surveys, United 

States, 1987 and 1991 aggregate data* 

African 

Americans 

American Indians/ 

Alaska Natives 

Asian Americans/ 

Characteristic Pacific Islanders 

Cigar smoking† 

Total 1.8 2.7 1.1 

Men 3.9 5.3 2.2 

Women 0.1 0.2 0.1 

Pipe smoking‡ 

Total 1.1 3.5 1.2 

Men 2.4 6.9 2.3 

Women 0.0 0.0 0.0 

Cigar or pipe smoking†‡ 

Total 2.5 4.9 1.7 

Men 5.6 9.8 3.3 

Women 0.1 0.2 0.1 

Any tobacco smokingΔ 

Total 32.6 36.4 16.0 

Men 40.2 37.3 24.0 

Women 26.5 35.6 7.8 

Use of chewing tobacco¶ 

Total 2.0 3.1 0.2 

Men 2.7 5.3 0.4 

Women 1.5 0.8 0.0 

Use of snuff** 

Total 1.4 1.8 0.5 

Men 0.9 3.2 0.9 

Women 1.9 0.4 0.0 

Use of chewing tobacco or snuff¶**

 Total 3.0 4.5 0.6 

Men 3.1 7.8 1.2 

Women 2.9 1.2 0.0 

Use of any tobacco product†† 

Total 35.2 40.2 16.8 

Men 42.4 43.9 25.6 

Women 29.3 36.6 7.9 

Note: For racial/ethnic-specific data on cigarette smoking, see Table 37. 

*95% confidence intervals do not exceed ±0.7% for whites, ±2.1% for African Americans, ±4.0% for Asian 

Americans and Pacific Islanders, ±9.6% for American Indians and Alaska Natives, ±0.7% for all nonHispanics, ±2.2% for all Hispanics, ±2.9% for Mexican Americans, ±7.0% for Puerto Ricans, ±8.0% for 

Cuban Americans, ±3.9% for other Hispanics, and ±0.7% for the total population. †

Includes persons who reported they had smoked at least 50 cigars in their lives and who reported at the time 

of survey that they currently smoked a cigar. 

‡

Includes persons who reported they had smoked a pipe at least 50 times in their lives and who reported at the 

time of survey that they currently smoked a pipe. 

§

Indicates a value of >0 and <0.05. 

smoking among men was highest among American ceremonial and addictive daily pipe smoking, and this 

Indians and Alaska Natives (9.8 percent) and lowest factor may partially account for the high prevalence 

among Puerto Ricans (1.5 percent). Unfortunately, the of pipe smoking among American Indian and Alaska 

1987 and 1991 NHISs did not distinguish between Native men. 

92 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Hispanics 

All 

Hispanics 

Cuban 

Americans 

Puerto 

Ricans 

Mexican 

Americans 

Other 

Hispanics Whites Total 

1.1 

2.1 

0.1 

1.0 

2.5 

0.0 

0.7 

1.3 

0.1 

0.6 

1.5 

0.0 

1.9 

3.8 

0.2 

2.3 

4.8 

0.1 

2.1 

4.4 

0.1 

0.5 

1.0 

0.0 

1.1 

2.6 

0.0 

0.1 

0.2 

0.0 

0.7 

1.5 

0.0 

0.8 

1.7 

0.0 

1.4 

2.9 

0.1 

1.3 

2.7 

0.0§ 

1.3 

2.7 

0.1 

2.1 

5.1 

0.0 

0.8 

1.5 

0.1 

1.2 

2.7 

0.0 

2.1 

4.3 

0.2 

3.3 

6.7 

0.1 

3.0 

6.2 

0.1 

22.7

29.3 

16.8 

22.5 

30.8 

16.9 

22.1 

29.4 

14.8 

26.8 

31.9 

23.1 

21.7 

27.2 

16.9 

29.6 

33.2 

26.3 

29.1 

33.4 

25.2 

0.4 

0.7 

0.1 

0.0 

0.0 

0.0 

0.4 

0.8 

0.1 

0.1 

0.3 

0.0 

0.5 

1.1 

0.1 

2.0 

4.1 

0.1 

1.8 

3.5 

0.3 

0.5 

1.0 

0.1 

0.1 

0.3 

0.0 

0.6 

1.0 

0.2 

0.3 

0.6 

0.0 

0.8 

1.6 

0.0 

1.9 

3.8 

0.3 

1.7 

3.2 

0.4 

0.8 

1.5 

0.1 

0.1 

0.3 

0.0 

0.9 

1.5 

0.3 

0.3 

0.6 

0.0 

1.1 

2.3 

0.1 

3.4 

6.8 

0.3 

3.1 

5.9 

0.6 

23.4 

30.4 

17.0 

22.7 

31.2 

17.0 

22.9 

30.7 

15.1 

27.4 

32.8 

23.3 

22.4 

28.4 

17.1 

32.2 

38.0 

26.8 

31.5 

37.6 

26.0 

Δ

Includes current users of cigarettes, cigars, or pipes.

¶Includes persons who reported they had used chewing tobacco at least 20 times in their lives and who reported 

at the time of survey that they currently chewed tobacco.

**Includes persons who reported they had used snuff at least 20 times in their lives and who reported at the 

time of survey that they currently used snuff. ††Includes users of cigarettes, cigars, pipes, chewing tobacco, or snuff. 

Source: Centers for Disease Control and Prevention 1994c. 

A 1996 survey of U.S. students aged 14–19 years each racial/ethnic group, males were significantly 

found that white (28.9 percent) and Hispanic (26.2 per- more likely than females to have smoked at least one 

cent) students were slightly more likely than African cigar during the previous year. Use among females 

American students (19.3 percent) to report having ranged from 13.4 percent in African Americans to 20.0 

smoked at least one cigar during the previous year. In percent among Hispanics. The prevalence of more 

Patterns of Tobacco Use 93 
 

Surgeon General's Report 

frequent cigar use did not differ by race/ethnicity; 3.6 

percent of African Americans, 2.5 percent of Hispanics, 

and 2.3 percent of whites reported that they had smoked 

at least 50 cigars during the previous year (CDC 1997b). 

Use of Smokeless Tobacco 

American Indians and Alaska Natives were the 

most likely (4.5 percent) to use chewing tobacco or snuff, 

according to aggregated data from the 1987 and 1991 

NHISs, whereas Asian Americans and Pacific Islanders (0.6 percent) as well as Hispanics (0.8 percent) were 

the least likely to use smokeless tobacco (Table 38). 

Conclusions 

Among all racial/ethnic groups except African Americans, men were much more likely than women to use 

chewing tobacco or snuff. Among African American 

women, the use of smokeless tobacco has been highest among those aged 65 years and older (CDC 1994c). 

These findings are consistent with those in published 

studies (Bauman et al. 1989; Novotny et al. 1989; Rouse 

1989), although they differ somewhat from the 1985 

CPS estimates for males aged 16 years and older; these 

estimates showed rates of reported snuff use among 

African Americans (0.7 percent) and whites (2.2 percent) that were significantly lower than the NHISbased rates reported here (Marcus et al. 1989). 

1.	 In 1978–1995, the prevalence of cigarette smoking 

declined among African American, Asian American and Pacific Islander, and Hispanic adults. 

However, among American Indians and Alaska 

Natives, current smoking prevalence did not 

change for men from 1983 to 1995 or for women 

from 1978 to 1995. 

2.	 Tobacco use varies within and among racial/ 

ethnic groups; among adults, American Indians 

and Alaska Natives have the highest prevalence 

of tobacco use; African American and Southeast 

Asian men also have a high prevalence of smoking. Asian American and Hispanic women have 

the lowest prevalence. 

3.	 In all racial/ethnic groups discussed in this report 

except American Indians and Alaska Natives, men 

have a higher prevalence of cigarette smoking than 

women. 

4.	 In all racial/ethnic groups except African Americans, men are more likely than women to use 

smokeless tobacco. 

5.	 Cigarette smoking prevalence increased in the 

1990s among African American and Hispanic adolescents after several years of substantial decline 

among adolescents of all four racial/ethnic minority groups. This increase is particularly striking 

among African American youths, who had the 

greatest decline of the four groups during the 1970s 

and 1980s. 

and Alaska Native women of reproductive age and 

has not declined as it has among African American, Asian American and Pacific Islander, and 

Hispanic women of reproductive age. 

6.	 Since 1978, the prevalence of cigarette smoking has 

remained strikingly high among American Indian 

7.	 Declines in smoking prevalence were greater 

among African American, Hispanic, and white 

men who were high school graduates than they 

were among those with less formal education. 

Among women in these three groups, educationrelated declines in cigarette smoking were less 

pronounced. 

8.	 Educational attainment accounts for only some of 

the differences in smoking behaviors (current 

smoking, heavy smoking, ever smoking, and 

smoking cessation) between whites and the racial/ 

ethnic minority groups discussed in this report. 

Other biological, social, and cultural factors are 

likely to further account for these differences. 

9.	 Compared with whites who smoke, smokers in 

each of the four racial/ethnic minority groups 

smoke fewer cigarettes each day. Among smokers, African Americans, Asian Americans and Pacific Islanders, and Hispanics are more likely than 

whites to smoke occasionally (less than daily). 

10. The data in general suggest that acculturation influences smoking patterns in that individuals tend 

to adopt the smoking behavior of the current 

broader community; however, the exact effects of 

acculturation on smoking behavior are difficult to 

quantify because of limitations on most available 

measures of this cultural learning process. 

94 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Appendix 1. Sources of Data 

Most of the data reported in this chapter were 

collected through a number of large-scale surveys 

conducted by the federal government or private 

researchers. When data from one period were insufficient (e.g., because of small sample size) for estimating the prevalence of a risk factor or a behavior, they 

were combined with similar data for several periods, 

provided the prevalence under consideration had not 

changed rapidly over the periods being aggregated. 

This process, used in some of the NHIS and BRFSS 

analyses, increased the reliability and stability of prevalence estimates (CDC 1992e). 

The data reported in this chapter are limited 

in several ways. For example, because some racial/ 

ethnic groups were underrepresented in the data 

sources, the small number of responses may not be 

representative of the group as a whole. Moreover, 

most surveys have been conducted in English only, 

thus limiting the validity of the responses of individuals with limited proficiency in English, particularly 

among Asian Americans, Pacific Islanders, and Hispanics. In addition, some surveys have used telephone surveys (excluding persons who lack telephone 

service) or school surveys (excluding youths who 

dropped out of school or who were frequently absent 

from class); these surveys have thus excluded a number of respondents who may be at increased risk for 

cigarette smoking. Despite these limitations, the patterns described in this chapter are the first and largest 

effort to present a comprehensive perspective on cigarette use among members of racial/ethnic minority 

groups in the United States. 

National Health Interview Survey (NHIS) 

Since 1965, the CDC’s NCHS has collected data 

on tobacco use through the NHIS, which uses a probability sample of noninstitutionalized adult civilians 

in the United States (NCHS 1975, 1985a, 1989). Some 

NHISs have excluded adults 18 and 19 years of age; 

however, this report uses data from surveys that have 

included respondents who were aged 18 years and 

older (i.e., 1978, 1979, 1980, 1983, 1985, 1987, 1988, 1990, 

1991, 1992, 1993, 1994, and 1995). Most interviews were 

conducted in the home; when respondents could not 

be interviewed in person, telephone interviews 

were conducted. The overall NHIS response rate for 

surveys on smoking has remained at least 85 percent 

(NCHS 1985a). Overall, sample sizes have ranged from 

10,342 in 1980 to 86,332 in 1966. In this report, data 

have been adjusted for nonresponse and have been 

weighted to provide national estimates. Confidence 

intervals have been calculated by using standard errors generated by the Professional Software for 

Survey Data Analysis (SUDAAN) (Shah et al. 1991). 

Responses from various administrations of the NHIS 

have been aggregated to produce more stable results 

for Hispanics, Asian Americans and Pacific Islanders, 

and American Indians and Alaska Natives. 

Hispanic Health and Nutrition 

Examination Survey (HHANES) 

The NCHS conducted the HHANES from 1982 

through 1984 to assess the health and nutritional 

status and needs of Cuban Americans, Mexican Americans, and mainland Puerto Ricans. No other equivalent source of recent data is available for Hispanics. 

This survey sampled Mexican Americans from Arizona, California, Colorado, New Mexico, and Texas; 

Cuban Americans from Dade County, Florida (Miami); 

and Puerto Ricans from New York, New Jersey, and 

Connecticut. Demographic and cigarette smoking information were collected from Hispanics aged 20–74 

years. All interviews were conducted in the home or 

in a mobile examination center. NCHS estimates that 

the HHANES data represent approximately 76 percent 

of the 1980 Hispanic-origin population. All data in 

this report have been adjusted and weighted for the 

complex sample design, nonresponse bias, potential 

noncoverage bias, and regional nature of the sample 

(NCHS 1985b). 

Behavioral Risk Factor Surveillance 

System (BRFSS) 

The CDC’s National Center for Chronic Disease 

Prevention and Health Promotion coordinates the state 

surveillance of behavioral risk factors through the 

BRFSS, initiated in 1981 (Gentry et al. 1985; Remington 

et al. 1988). Each state that participates in the BRFSS 

provides estimates of numerous risk behaviors for the 

state’s population of persons aged 18 years and older. 

Patterns of Tobacco Use 95 
 

Surgeon General's Report 

States collect data through random digit-dialed 

telephone interviews. BRFSS sample sizes have ranged 

from 476 in Indiana in 1984 to 3,988 in California in 

1992. Since 1991, at least 1,178 persons have been 

sampled in each state. In this report, the data have 

been weighted to reflect the age, race/ethnicity, and 

gender distribution of each participating state. Ninetyfive percent confidence intervals have been calculated 

by using the Standard Errors Program for Computing 

of Standardized Rates from Sample Survey Data 

(SESUDAAN) (Shah 1981). 

Adult Use of Tobacco Survey (AUTS) 

Since 1964, the AUTS has been conducted periodically to determine rates of tobacco use as well as 

descriptive information on smoking patterns among 

representative samples of the U.S. population. Information gathered has included a history of individual 

use of any tobacco product as well as attitudes and 

beliefs about smoking-related issues. The AUTS was 

conducted in 1964, 1966, 1970, and 1975 by the 

USDHEW's National Clearinghouse for Smoking and 

Health, and the most recent survey was conducted in 

1986 by the CDC’s Office on Smoking and Health. In 

the 1986 AUTS, a computer-assisted telephone interview protocol (random-digit dialing) was used to survey 13,031 noninstitutionalized civilian U.S. adults 

(>17 years of age). Population estimates were obtained 

by weighting the sample according to smoking status, 

age, race/ethnicity, gender, education, and geographic 

region (USDHHS 1990b). 

Monitoring the Future (MTF) Surveys 

Each spring since 1975, the University of 

Michigan’s Institute for Social Research, with grants 

from NIDA, has surveyed nationally representative 

samples of high school seniors as part of the MTF. 

Sample sizes have ranged from 15,850 to 18,448. The 

data in this report have been weighted to provide national estimates. Analyses were conducted on data 

collected for 1976–1994. Data from subsequent years 

were obtained from published reports (e.g., Johnston 

et al. 1996) and from the University of Michigan’s Institute for Social Research. Since 1991, data have been 

collected for eighth- and tenth-grade students. Some 

data from these surveys are cited in this report 

(Johnston et al. 1993b, 1995a, 1996). 

Youth Risk Behavior Survey (YRBS) 

The CDC developed the Youth Risk Behavior Surveillance System to measure six categories of priority 

health-risk behaviors, including tobacco use, among 

adolescents. Data were collected through national, 

state, and local school-based surveys of high school students, conducted during the spring of odd-numbered 

years, and a national household-based survey of youths 

aged 12–21 years, conducted during 1992 (Kolbe 1990; 

Kolbe et al. 1993; CDC 1996). Data from the 1991 and 

1995 national school-based surveys and the 1992 national household survey are cited in this report 

(USDHHS 1994; CDC 1996; Lowry et al. 1996). 

The national school-based YRBSs each used a 

three-stage cluster sample design to draw a nationally 

representative sample of ninth- to twelfth-grade students in public and private schools in all 50 states and 

the District of Columbia. Schools having a substantial 

proportion of African American and Hispanic students 

were oversampled. The questionnaire was administered in the classroom by trained data collectors. The 

data were weighted to provide national estimates. 

The 1992 YRBS was a follow-back survey to the 

1992 NHIS. The sample of young people aged 12–21 

years was drawn from families who were interviewed 

for the 1992 NHIS. Participants responded in person. 

Respondents listened through a headset to an audiocassette containing previously recorded questions. 

Respondents recorded their responses on answer 

sheets, which were returned to the interviewers in 

sealed envelopes. The data were weighted to provide 

national estimates. 

Teenage Attitudes and Practices Survey 

(TAPS) 

In 1989 and 1993, the U.S. Public Health Service 

conducted the TAPS to collect data on knowledge, attitudes, and practices regarding tobacco use from a 

national household sample of adolescents (aged 12–18 

years) through telephone interviews. The 1993 TAPS 

included a longitudinal component (TAPS-II) in which 

7,960 (87.1 percent) of the 9,135 respondents to the 1989 

TAPS were reinterviewed; these respondents were 15– 

22 years of age during TAPS-II. TAPS-II also included 

4,992 persons from a new probability sample. In this 

report, data on 9,135 TAPS respondents and 7,311 TAPSII respondents have been analyzed. Data have been 

weighted to provide national estimates, and confidence 

intervals have been calculated by using the standard 

errors generated by the SUDAAN (Shah et al. 1991). 

96 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Appendix 2. Measures of Tobacco Use 

Several measures of tobacco use among members 

of racial/ethnic groups can be derived from state and 

national surveys and other data sources. The most 

common measures include cigarette smoking and cessation; the number of cigarettes smoked daily; and the 

use of cigars, pipes, and smokeless tobacco. 

Cigarette Smoking and Cessation 

The NHIS gathers information on a range of cigarette smoking behaviors, using some of the following 

terms and measurements: 

•	 For 1978–1991, current smokers are defined as those 

who have smoked 100 or more cigarettes in their 

lifetime and who report at the time of survey that 

they currently smoke. For 1992–1995, current 

smokers are defined as those who have smoked at 

least 100 cigarettes in their lives and who report at 

the time of survey that they currently smoke every day or on some days. 

•	 Former smokers are those who have smoked 100 or 

more cigarettes in their lifetime and who do not 

currently smoke. 

•	 Never smokers are those who have smoked fewer 

than 100 cigarettes in their lifetime. 

•	 Ever smokers consist of current smokers and former 

smokers.

 •	 The prevalence of cessation (or quit ratio) is defined 

as the percentage of ever smokers who are former 

smokers (Fiore et al. 1989; USDHHS 1989, 1990a). 

NHIS data on age at initiation of regular smoking and on duration of abstinence for former smokers 

have been used to reconstruct the prevalence of cigarette smoking for the decades in this century before 

systematic surveillance of cigarette smoking was 

conducted (NCI 1991). Information such as the 

respondent’s date of birth, age at initiation of smoking, and age at cessation for former smokers can be 

used to assess the smoking status of a respondent for 

any given year. Similar analyses have been reported 

in previous Surgeon General’s reports (USDHHS 1980, 

1985) and in the literature (Harris 1983; Escobedo and 

Remington 1989; Pierce et al. 1991b). 

The BRFSS has routinely reported estimates of 

“regular” cigarette smoking. Current regular smokers are defined as those (1) who report that they have 

smoked ≥100 cigarettes and that they currently smoke 

and (2) who do not respond that they are occasional 

smokers when asked to report the average number of 

cigarettes they smoke daily. The use of a measure of 

current regular smoking generally results in median 

prevalence estimates that are about 0.7 to 1.0 percentage points lower than those estimates that include 

current occasional smokers (CDC 1994c). The BRFSS 

defines and calculates the prevalence of smoking cessation in the same manner as is done in the NHIS. 

In the MTF surveys, current cigarette use patterns 

are defined as any use of cigarettes within the 30 days 

preceding the survey. This same definition was used 

for current alcohol, marijuana, cocaine, and any other 

illicit drug use. 

Number of Cigarettes Smoked Daily 

Cigarette consumption traditionally has been 

reported in three categories: (1) smoking fewer than 

15 cigarettes per day, (2) smoking between 15 and 24 

cigarettes per day, and (3) smoking 25 or more cigarettes per day. In the NHISs and the BRFSS surveys, 

respondents were asked to report the actual number 

of cigarettes smoked per day. 

In the 1978–1991 NHISs, cigarette consumption 

was defined as the average number of cigarettes that 

current smokers reported smoking each day. Starting 

in 1992, however, current smokers who reported that 

they smoked only on some days were asked to report 

the number of days out of the past 30 days that they 

smoked any cigarettes and the average number of cigarettes they smoked on the days that they smoked. 

The MTF survey asks respondents how frequently they have smoked during the previous 30 

days. Possible responses are “not at all,” “less than 

one cigarette per day,” “one to five cigarettes per day,” 

“about one-half pack per day,” “about one pack per 

day,” “about one and one-half packs per day,” and 

“two packs or more per day.” 

Use of Cigars, Pipes, and Smokeless Tobacco 

The 1987 and 1991 NHISs defined current cigar 

smokers as those who had smoked 50 or more cigars 

in their lifetime and who were current cigar smokers, 

and they defined current pipe smokers as those who 

had smoked 50 or more pipes full of tobacco and who 

Patterns of Tobacco Use 97 
 

Surgeon General's Report 

were current pipe smokers. Current snuff users were 

defined as those who had used snuff 20 or more times 

and were currently snuff users. The same logic was 

used to classify chewing tobacco users. 

In the BRFSS surveys, smokeless tobacco users 

were defined as those who said that they had ever used 

smokeless tobacco (such as chewing tobacco or snuff) 

and who were current users of any smokeless tobacco 

products. 

Appendix 3. Patterns of Cigarette Use Among Whites 

Table 39. Percentage of white adults who reported being current cigarette smokers,* overall and by gender, 

age, and education, National Health Interview Surveys, United States, 1965–1995 

Characteristic 

1965 ____________ 

% ±CI‡

1966 ____________ 

% ±CI

1970 ____________ 

% ±CI 

1974 ____________ 

% ±CI 

Total 42.1 0.6 42.4 0.5 37.0 0.7 36.4 0.8 

Gender 

Men 

Women 

51.1 0.8 51.8 0.8 43.2 0.8 41.9 1.0 

34.0 0.7 33.9 0.7 31.6 1.0 31.7 1.1 

Age (years) 

18–34 

35–54 

≥55 

48.6 1.0 48.3 0.9 41.3 1.0 40.7 1.6 

48.5 0.9 48.7 0.9 42.8 0.9 41.9 1.1 

26.3 0.9 27.4 0.9 25.1 0.9 24.9 1.1 

Education§ 

Less than high school 

High school 

Some college 

College 

NA NA 41.3 0.9 37.1 1.0 36.9 1.3 

41.9Δ 0.7 44.3 1.0 39.0 0.9 38.1 1.3 

NA NA 44.4 1.8 38.5 1.4 37.9 2.0 

40.4Δ 1.3 35.2 1.8 28.6 1.5 28.2 1.7 

1985 ____________ 

% ±CI

1987 ____________ 

 % ±CI

1988 ____________ 

 % ±CI 

1990 ____________ 

Characteristic % ±CI 

Total 29.9 0.7 29.0 0.7 28.2 0.6 25.9 0.6 

Gender 

Men 

Women 

31.8 1.0 30.6 0.9 30.3 0.9 27.8 0.9 

28.2 0.9 27.5 0.8 26.3 0.7 24.1 0.8 

Age (years) 

18–34 

35–54 

≥55 

33.6 1.2 32.2 1.1 31.9 1.1 29.7 1.0 

33.7 1.2 33.7 1.0 32.1 1.0 29.9 1.0 

21.5 1.0 20.2 0.9 19.7 0.8 16.8 0.8 

Education§ 

Less than high school 

High school 

Some college 

College 

33.7 1.6 34.8 1.6 33.7 1.3 32.0 1.5 

33.1 1.2 32.6 1.1 32.6 1.0 30.0 1.0 

30.3 1.6 28.5 1.3 27.8 1.3 24.9 1.2 

18.3 1.2 16.9 1.0 16.2 1.0 13.7 0.9 

*Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; 

these data exclude those whites who indicated they were of Hispanic origin. For 1978–1991, current cigarette 

smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the 

time of survey that they currently smoked. For 1992–1995, current smokers include persons who reported 

smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked 

every day or on some days. 

98 Chapter 2 
Patterns of Tobacco Use 99 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1976†

____________ 

% ±CI 

1977†

____________ 

% ±CI

 1978 ____________ 

% ±CI

 1979 ____________ 

% ±CI 

1980 ____________ 

% ±CI 

1983 ____________ 

% ±CI 

35.9 0.7 35.0 0.7 34.0 1.2 33.4 0.8 33.0 1.1 32.3 0.7 

40.7 1.1 39.0 1.0 37.3 1.9 36.6 1.0 36.5 1.6 34.6 1.1 

31.9 1.0 31.8 1.1 31.1 1.3 30.6 1.0 29.8 1.5 30.2 0.9 

40.0 1.2 38.9 1.5 37.0 1.8 37.3 1.3 35.2 1.8 36.0 1.2 

41.2 1.4 41.1 1.1 40.5 2.0 38.4 1.3 38.8 2.0 37.4 1.3 

25.0 1.1 25.1 1.1 23.6 1.7 23.6 0.9 24.3 1.6 22.5 1.1 

36.6 1.5 35.7 1.3 35.6 2.2 35.1 1.5 35.5 2.0 35.3 1.6 

37.6 1.4 37.8 1.4 37.0 1.9 35.3 1.3 34.9 2.0 34.8 1.3 

37.6 2.1 37.0 1.8 34.1 3.1 35.7 1.8 33.9 3.1 32.8 1.9 

27.2 1.7 25.9 1.7 23.8 2.6 23.2 1.6 24.4 2.3 20.1 1.5 

1991 ____________ 

% ±CI

1992 ____________ 

% ±CI

1993 ____________ 

% ±CI 

1994 ____________ 

% ±CI 

1995 ____________ 

% ±CI 

26.0 0.6 27.2 0.8 25.4 0.8 25.5 0.7 25.6 1.0 

27.5 0.9 28.6 1.2 27.0 1.2 28.2 1.1 27.1 1.5 

24.6 0.7 25.9 1.1 24.0 1.0 23.1 0.9 24.1 1.3 

29.8 1.0 32.8 1.5 30.1 1.4 29.3 1.4 29.7 1.8 

30.0 1.0 30.1 1.3 29.3 1.4 28.9 1.2 28.3 1.6 

17.3 0.8 17.5 1.2 15.8 1.1 16.2 1.1 17.8 1.3 

33.3 1.5 32.0 2.0 31.8 2.6 31.9 1.8 33.3 2.6 

30.6 0.9 31.9 1.4 29.1 1.3 29.8 1.3 30.2 1.7 

24.9 1.2 25.9 1.7 24.9 1.7 25.7 1.7 24.1 1.9 

13.8 0.9 14.8 1.3 13.5 1.3 12.3 1.1 14.0 1.6 

†

The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
 

were statistically adjusted to produce estimates for the total population, males, and females that approximate
 

those for whites aged 18 years and older. Estimates for persons in the 18–34 year old age category were statistically adjusted to produce estimates that approximate those for whites aged 18–34 years.


‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.


ΔLevels presented for 1965 are for persons who had a high school education or less and persons who attended
 

some college or were college graduates. 

NA = data not available. 

Source: National Center for Health Statistics, public use data tapes, 1965–1995. 
 

<

<

<

<

<

 

<

<

<15–24 cigarettes 

<

<15–24 cigarettes 

Surgeon General's Report 

Table 40.	 Percentage of adult white smokers* who reported smoking <15, 15–24, and ≥ 25 cigarettes per day, 

overall and by gender, age, and education, National Health Interview Surveys, United States, 

1965–1995

 1965 1966 1970 1974 ____________ ____________ ____________ ____________ 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI 

Total 

<15 cigarettes 33.1 1.1 31.7 0.8 29.7 0.9 27.7 1.2 

15–24 cigarettes 45.3 0.8 45.9 0.9 45.0 0.9 44.7 1.2 

≥25 cigarettes 21.6 0.7 22.4 0.7 25.4 0.9 27.6 1.1 

Gender 

Men 

<15 cigarettes 26.6 1.0 25.8 1.0 24.4 1.2 21.5 1.6 

15–24 cigarettes 46.7 1.1 47.2 1.2 45.2 1.2 44.5 1.9 

≥25 cigarettes 26.7 0.9 27.0 1.0 30.4 1.2 34.1 1.7 

Women 

<15 cigarettes 41.8 1.3 39.5 1.2 35.9 1.1 34.5 1.7 

15–24 cigarettes 43.4 1.3 44.3 1.3 44.7 1.1 45.0 1.6 

≥25 cigarettes 14.8 0.9 16.2 1.0 19.4 0.9 20.5 1.2 

Age (years) 

18–34 

<15 cigarettes 34.7 1.4 33.9 1.3 31.6 1.2 30.9 1.8 

15–24 cigarettes 47.4 1.5 48.2 1.3 46.9 1.2 46.3 1.8 

≥25 cigarettes 17.9 1.1 17.9 1.0 21.6 1.2 22.8 1.6 

35–54 

<15 cigarettes 29.0 1.1 26.7 1.1 24.7 1.1 21.4 1.6 

15–24 cigarettes 45.1 1.2 45.5 1.3 44.2 1.2 42.9 1.8 

≥25 cigarettes 28.0 1.2 27.8 1.1 31.1 1.1 35.7 1.7 

≥55 

<15 cigarettes 40.1 1.9 38.8 1.9 36.3 1.6 32.7 2.4 

15–24 cigarettes 41.5 1.9 42.2 1.9 42.7 1.4 44.7 2.4 

≥25 cigarettes 18.4 1.5 18.8 1.5 21.1 1.5 22.7 2.3 

Education§ 

Less than high school 

<15 cigarettes NA NA 30.7 1.3 28.6 1.5 25.7 2.0 

15–24 cigarettes NA NA 45.8 1.3 44.3 1.2 45.1 2.1 

≥25 cigarettes NA NA 23.5 1.2 27.0 1.4 29.2 1.8 

High school 

<15 cigarettes 

≥25 cigarettes 

31.1Δ 1.0 28.5 1.4 26.2 1.4 25.7 2.0 

45.9Δ 1.1 46.9 1.7 47.3 1.4 44.7 2.3 

23.0Δ 0.9 24.6 1.4 26.5 1.3 29.6 1.9 

Some college 

<15 cigarettes NA NA 29.4 2.7 27.1 2.4 23.1 3.1 

15–24 cigarettes NA NA 44.6 3.0 43.1 2.8 42.7 3.3 

≥25 cigarettes NA NA 26.0 2.6 29.8 2.2 34.2 2.6 

College 

<15 cigarettes 

≥25 cigarettes 

33.2Δ 2.0 35.0 3.1 31.7 2.1 27.9 3.9 

42.3Δ 2.2 39.2 3.2 40.2 2.8 43.0 3.8 

24.5Δ 2.0 25.9 2.8 28.1 3.1 29.1 3.4 

*Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; these data 

exclude those whites who indicated they were of Hispanic origin. For 1965–1991, current cigarette smokers include 

persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that they 

currently smoked. For 1992–1995, current smokers include persons who reported smoking at least 100 cigarettes in 

their lives and who reported at the time of survey that they currently smoked every day or on some days.
 

NA = data not available.
 

Source: National Center for Health Statistics, public use data tapes, 1965–1995.
 

100 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1976†

____________ 

% ±CI 

1977†

____________ 

% ±CI

 1978 ____________ 

% ±CI 

1979 ____________ 

% ±CI

1980 ____________ 

% ±CI

1983 ____________ 

% ±CI 

27.8 1.2 26.9 1.2 23.7 1.5 24.4 1.0 23.2 1.6 23.8 1.2 

45.2 1.3 43.6 1.4 44.7 1.7 44.7 1.3 44.6 1.9 46.8 1.4 

27.0 1.2 27.5 1.4 31.6 1.6 30.9 1.2 32.2 1.9 29.4 1.3 

22.0 1.6 20.5 1.3 17.8 1.9 20.0 1.2 17.7 2.2 17.8 1.5 

45.2 1.6 41.6 1.7 43.6 2.5 43.1 1.7 44.3 2.7 45.1 2.0 

32.8 1.7 33.5 1.8 38.6 2.3 36.9 1.7 38.0 2.7 37.1 1.6 

34.0 1.7 33.7 1.6 30.1 2.4 29.2 1.6 29.3 2.1 30.1 1.7 

45.1 1.8 45.8 1.9 45.8 2.3 46.5 1.9 44.8 2.6 48.4 1.9 

21.0 1.5 21.0 1.6 24.1 2.3 24.4 1.5 25.9 2.3 21.5 1.6 

30.0 1.8 29.9 1.7 25.2 2.2 26.5 1.7 25.2 2.7 27.5 1.9 

47.3 1.9 45.9 1.9 47.8 2.6 47.4 1.8 48.0 2.9 49.9 2.0 

22.6 1.9 21.9 2.1 27.0 2.7 26.1 1.5 26.9 2.6 22.7 1.7 

22.7 1.7 21.2 1.8 19.0 2.3 19.2 1.5 17.6 2.6 18.0 1.7 

43.3 2.0 42.6 2.0 41.5 2.7 41.8 2.2 40.5 2.9 42.6 2.2 

34.0 1.8 36.3 2.0 39.5 2.4 39.0 2.2 41.9 3.4 39.4 2.2 

32.0 2.5 31.6 2.6 28.9 3.6 28.8 2.6 28.7 3.2 26.0 2.5 

43.8 2.7 42.9 2.9 43.9 4.1 44.1 3.0 44.7 3.7 47.3 2.9 

24.2 2.3 25.6 2.5 27.2 3.7 27.2 2.5 26.6 3.3 26.7 2.5 

26.7 1.9 26.2 2.1 23.3 2.9 23.1 2.0 21.2 3.0 20.4 2.2 

44.5 2.2 43.3 2.7 44.1 3.3 44.0 2.6 44.9 3.7 45.4 2.9 

28.8 2.2 30.5 2.3 32.7 2.4 32.9 2.2 33.9 3.6 34.3 2.7 

24.2 1.8 22.7 1.7 22.4 2.5 20.5 1.7 21.0 2.7 21.3 1.8 

46.3 2.3 45.6 2.1 43.8 2.7 46.0 2.3 44.6 3.5 46.0 2.3 

29.5 2.2 31.7 2.1 33.8 2.9 33.5 2.1 34.4 3.4 32.7 2.2 

26.2 3.6 27.8 3.2 18.9 3.2 22.0 3.0 18.0 4.2 21.2 2.9 

41.8 3.4 41.4 3.6 44.2 5.7 42.1 3.2 45.9 5.5 46.3 3.6 

32.0 3.4 30.8 3.1 37.0 5.5 35.9 3.0 36.0 4.7 32.5 3.4 

30.4 3.7 30.4 3.1 25.8 5.2 29.6 3.7 27.7 5.0 28.4 3.8 

41.2 4.4 40.2 3.8 41.1 5.9 37.2 3.9 35.2 5.4 40.9 4.2 

28.4 3.3 29.4 3.7 33.2 4.7 33.2 3.6 37.1 5.7 30.7 4.2 

†The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
 

were statistically adjusted to produce estimates for the total population, males, and females that approximate
 

those for whites aged 18 years and older. Estimates for persons in the 18–34 year old age category were statistically adjusted to produce estimates that approximate those for whites aged 18–34 years.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.


ΔLevels presented for 1965 are for persons who had a high school education or less and persons who
 

attended some college or were college graduates.
 

Patterns of Tobacco Use 101 
 

<

<

<

<

<

 

<

<

<

<

<

Surgeon General's Report 

Table 40. Continued

 1985 1987 1988 1990 ____________ ____________ ____________ ____________ 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI 

Total 

<15 cigarettes 26.1 1.1 25.4 1.0 24.7 1.0 27.9 1.1 

15–24 cigarettes 43.6 1.3 43.7 1.1 45.7 1.1 45.2 1.2 

≥25 cigarettes 30.3 1.2 30.9 1.1 29.6 1.0 26.9 1.2 

Gender 

Men 

<15 cigarettes 20.1 1.6 20.6 1.4 20.4 1.3 21.7 1.4 

15–24 cigarettes 42.6 1.9 40.6 1.6 43.9 1.6 43.9 1.8 

≥25 cigarettes 37.3 1.8 38.8 1.6 35.7 1.6 34.5 1.9 

Women 

<15 cigarettes 32.1 1.6 30.3 1.5 29.3 1.5 34.5 1.6 

15–24 cigarettes 44.7 1.7 46.9 1.6 47.5 1.6 46.6 1.6 

≥25 cigarettes 23.2 1.4 22.8 1.4 23.3 1.2 19.0 1.4 

Age (years) 

18–34 

<15 cigarettes 31.1 1.9 29.8 1.7 29.3 1.7 34.9 1.9 

15–24 cigarettes 45.2 2.0 45.6 1.8 47.7 1.8 47.3 1.9 

≥25 cigarettes 23.8 1.7 24.6 1.5 22.9 1.5 17.8 1.6 

35–54 

<15 cigarettes 19.0 1.7 20.1 1.6 18.1 1.5 20.4 1.6 

15–24 cigarettes 41.1 2.1 41.3 1.8 43.7 1.8 43.4 2.0 

≥25 cigarettes 39.9 2.1 38.6 1.5 38.3 1.8 36.2 2.0 

≥55 

<15 cigarettes 27.7 2.4 26.3 1.6 27.7 2.0 29.1 2.5 

15–24 cigarettes 44.7 2.6 44.6 1.8 45.0 2.2 44.5 2.5 

≥25 cigarettes 27.6 2.3 29.2 1.9 27.2 2.1 26.4 2.3 

Education§ 

Less than high school 

<15 cigarettes 19.5 2.2 19.9 2.1 19.1 1.8 19.5 2.2 

15–24 cigarettes 44.3 2.7 44.2 2.4 44.5 2.4 48.6 2.9 

≥25 cigarettes 36.2 2.7 35.8 2.4 36.5 2.4 31.9 2.7 

High school 

<15 cigarettes 23.1 1.8 22.8 1.5 20.5 1.4 24.5 1.7 

15–24 cigarettes 44.5 2.1 43.4 1.8 47.7 1.8 45.8 1.9 

≥25 cigarettes 32.4 1.9 33.8 1.8 31.8 1.6 29.6 1.8 

Some college 

<15 cigarettes 26.3 2.8 24.9 2.3 25.6 2.3 27.8 2.6 

15–24 cigarettes 42.0 3.1 43.0 2.8 43.2 2.7 43.5 3.1 

≥25 cigarettes 31.7 2.9 32.2 2.7 32.2 2.4 28.7 2.8 

College 

<15 cigarettes 30.5 3.4 31.0 3.1 32.4 2.9 35.1 3.3 

15–24 cigarettes 37.9 3.7 39.9 3.4 39.5 3.2 39.6 3.4 

≥25 cigarettes 31.6 3.6 29.2 3.0 28.1 2.9 25.3 3.3 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

102 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups

 1991 ____________ 

% ±CI 

1992 ____________ 

% ±CI

 1993 ____________ 

% ±CI

1994 ____________ 

% ±CI

1995 ____________ 

% ±CI 

29.8 1.2 31.7 1.5 32.5 1.7 35.6 1.8 35.0 2.0 

45.0 1.3 43.3 1.6 44.9 1.7 44.4 1.9 41.8 2.1 

25.2 1.2 25.0 1.4 22.6 1.4 20.0 1.4 23.2 1.8 

24.6 1.6 25.8 1.9 27.5 2.4 30.5 2.5 28.0 2.6 

43.4 1.7 41.8 2.4 43.0 2.5 44.3 2.7 41.6 3.0 

31.9 1.8 32.4 2.2 29.5 2.3 25.1 2.2 30.4 2.8 

35.0 1.6 37.7 2.3 37.6 2.3 40.8 2.5 42.3 2.8 

46.6 1.7 44.9 2.2 46.8 2.4 44.5 2.4 41.9 2.8 

18.4 1.3 17.4 1.6 15.6 1.8 14.6 1.9 15.8 2.0 

36.5 2.0 37.4 2.6 39.5 3.0 42.5 3.0 44.3 3.4 

46.1 2.1 43.9 2.5 45.6 2.8 45.4 3.1 41.1 3.4 

17.5 1.7 18.6 2.2 15.0 2.0 12.1 1.7 14.6 2.9 

23.9 1.6 26.8 2.3 27.6 2.6 29.6 2.6 31.0 3.0 

43.4 1.9 42.3 2.8 44.1 2.5 42.9 2.6 41.6 3.0 

32.7 1.9 30.9 2.4 28.3 2.4 27.6 2.5 27.4 2.6 

29.1 2.1 29.9 3.2 30.0 3.4 34.6 3.6 27.0 3.4 

46.2 2.4 44.2 3.6 45.2 4.1 45.9 4.1 43.2 4.2 

24.7 2.2 25.9 2.9 24.8 3.1 19.5 3.2 29.8 4.2 

21.4 2.2 24.6 3.2 25.3 3.5 25.6 3.5 19.9 3.7 

43.8 2.6 41.5 3.7 45.9 4.0 44.5 4.5 45.4 4.8 

34.8 2.7 33.9 3.7 28.8 3.7 29.9 4.1 34.7 4.6 

25.7 1.6 26.7 2.3 28.2 2.5 30.5 2.7 29.2 2.8 

47.7 1.9 46.3 2.8 46.2 2.7 46.8 2.9 45.0 3.1 

26.6 1.9 27.0 2.4 25.6 2.4 22.7 2.3 25.8 3.0 

33.0 2.7 33.7 3.7 34.0 3.7 36.8 4.4 40.2 4.6 

43.6 2.9 42.0 3.6 44.3 4.3 44.0 4.0 39.2 4.6 

23.4 2.4 24.3 3.5 21.8 3.4 19.2 3.3 20.6 3.8 

35.3 3.4 43.2 4.5 42.1 5.4 48.7 5.4 50.6 5.6 

42.9 3.4 37.6 4.6 37.7 5.0 36.9 5.3 34.0 5.5 

21.8 2.9 19.2 4.1 20.2 3.8 14.4 3.7 15.4 3.8 

Patterns of Tobacco Use 103 
 

 

 

*Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; 

these data exclude those whites who indicated they were of Hispanic origin. The prevalence of cessation is the 

percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at 

least 100 cigarettes in their lives and who reported at the time of survey that they were not smoking, and ever 

smokers include current and former smokers. 

†

The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 

were statistically adjusted to produce estimates for the total population, males, and females that approximate 

those for whites aged 18 years and older. Estimates for persons in the 18-34 year old age category were statistically adjusted to produce estimates that approximate those for whites aged 18-34 years. 

Surgeon General's Report 

Table 41.	 Percentage of adult white ever smokers who have quit,* overall and by gender, age, and 

education, National Health Interview Surveys, United States, 1965–1995 

Characteristic 

1965 ____________ 

% ±CI‡

1966 ____________ 

% ±CI

1970 ____________ 

% ±CI 

1974 ____________ 

% ±CI 

Total 25.2 0.6 25.3 0.6 34.3 0.8 36.1 0.9 

Gender

 Men 

 Women 

28.9 0.8 28.9 0.8 39.0 1.0 41.0 1.1

19.6 0.9 19.6 0.9 27.8 0.9 29.6 1.4 

Age (years)

 18–34 

35–54 

≥55 

17.6 0.9 16.9 0.9 25.9 1.1 26.2 1.7

24.5 1.0 25.0 0.9 33.5 1.1 35.2 1.2 

38.3 1.6 38.2 1.5 47.5 1.3 51.0 1.8 

Education§

 Less than high school 

High school 

Some college 

College 

NA NA 26.4 1.0 34.6 1.2 36.2 1.6

25.4Δ 0.8 25.1 1.2 34.5 1.0 36.3 1.5

NA NA 28.4 2.2 37.1 1.6 39.5 2.5

33.2† 1.6 38.5 2.3 49.7 2.3 50.6 2.4 

Characteristic 

1985 ____________ 

% ±CI

1987 ____________ 

% ±CI

1988 ____________ 

% ±CI 

1990 ____________ 

% ±CI 

Total 46.6 1.0 46.2 0.9 47.7 0.9 50.9 1.0 

Gender

 Men 

 Women 

51.0 1.3 50.5 1.2 51.1 1.2 54.2 1.3

41.0 1.3 40.9 1.3 43.5 1.1 47.0 1.2 

Age (years)

 18–34 

35–54 

≥55 

32.4 1.5 31.4 1.4 32.3 1.5 35.1 1.6

46.2 1.6 44.6 1.5 45.9 1.4 48.6 1.5 

62.2 1.6 63.1 1.5 65.0 1.3 68.9 1.3 

Education§

 Less than high school 

High school 

Some college 

College 

46.5 2.1 44.3 1.9 45.7 1.7 47.8 2.0

44.5 1.6 44.8 1.4 45.0 1.4 48.2 1.5

48.7 2.3 48.9 1.9 50.7 1.9 54.0 1.9

63.7 2.2 63.0 2.1 64.6 1.8 68.7 1.9 

104 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1976†

% ±CI

 1977†

 % ±CI

 1978

 % ±CI 

 1979 

% ±CI 

1980 

% ±CI 

1983 

% ±CI 

36.5 1.0 36.3 1.0 39.5 1.7 40.5 1.2 40.8 1.7 42.0 1.0 

41.3 1.3 41.4 1.1 44.7 2.1 45.3 1.3 45.2 2.1 46.6 1.4 

30.4 1.5 30.0 1.5 32.8 2.0 34.3 1.7 35.0 2.4 36.2 1.4 

25.3 1.3 26.8 1.8 29.1 2.3 29.4 1.5 30.5 2.3 29.1 1.5 

36.5 1.7 35.2 1.5 36.7 2.6 39.7 1.8 39.8 2.6 40.3 1.7 

51.6 1.9 50.7 1.9 56.0 2.7 55.5 1.6 54.5 2.9 59.0 1.8 

37.1 1.9 36.8 1.7 39.1 2.7 41.2 1.9 39.7 3.0 41.5 2.1 

36.6 1.7 36.1 1.9 39.0 2.3 40.2 1.8 40.7 2.7 41.9 1.7 

39.7 2.8 39.4 2.2 44.9 3.9 41.7 2.4 43.5 4.3 44.6 2.6 

49.4 2.7 50.2 2.8 54.5 3.9 55.6 2.7 54.2 3.9 57.9 2.7 

1991 

% ±CI

1992 

 % ±CI

1993 

 % ±CI 

1994 

% ±CI 

1995 

% ±CI 

50.5 0.9 48.5 1.3 51.6 1.3 51.0 1.3 50.5 1.6 

54.2 1.2 52.0 1.7 54.6 1.7 53.7 1.7 52.9 2.2 

46.2 1.3 44.4 1.8 48.1 1.7 47.8 1.9 47.6 2.1 

31.9 1.5 27.4 2.0 31.4 2.0 29.0 2.2 31.5 2.6 

48.7 1.4 48.0 1.9 48.6 2.0 49.3 1.9 48.6 2.4 

68.8 1.3 68.1 2.0 71.8 1.8 72.1 1.8 68.0 2.2 

46.0 2.0 49.1 2.7 49.2 3.4 47.1 2.8 46.5 3.3 

48.0 1.4 45.6 2.0 49.8 1.9 48.5 2.1 47.2 2.4 

54.9 1.9 53.6 2.7 55.1 2.6 54.7 2.8 55.7 3.0 

67.8 1.8 64.2 2.6 68.1 2.6 70.8 2.6 66.1 3.4 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.


ΔLevels presented for 1965 are for persons who had a high school education or less and persons who
 

attended some college or were college graduates.
 

NA = data not available.
 

Source: National Center for Health Statistics, public use data tapes, 1965–1995.
 

Patterns of Tobacco Use 105 
 

Surgeon General's Report 

Table 42.	 Percentage of white women of reproductive age who reported being current cigarette smokers,* 

overall and by education, National Health Interview Surveys, United States, 1965–1995 

Characteristic 

1965 ––––––––––– 

% +CI‡

1966 ––––––––––– 

% +CI

1970 ––––––––––– 

% +CI

1974 ––––––––––– 

% +CI 

1976† 

––––––––––– 

% +CI 

Total 42.2 1.1 41.5 1.1 36.8 1.2 37.3 1.7 36.4 1.5 

Education§ 

Less than high school 

High school 

Some college 

College 

NA NA 48.0 2.2 46.7 2.0 50.5 3.1 49.4 4.4 

44.2 1.4 41.3 1.8 36.6 1.8 38.2 2.5 38.0 2.5 

NA NA 43.8 3.8 37.5 3.2 35.2 4.3 34.8 4.4 

41.3 2.9 34.6 4.4 27.2 2.6 25.5 3.3 25.0 3.4 

† 1977 ––––––––––– 

% +CI

1978 ––––––––––– 

 % +CI

1979 ––––––––––– 

 % +CI

1980 –––––––––––

 % +CI 

1983 ––––––––––– 

% +CI 

Total	 36.8 1.5 35.6 2.1 36.0 1.4 33.2 1.9 35.5 1.3 

Education§ 

Less than high school 47.6 3.9 56.1 5.9 52.0 3.9 53.9 7.0 53.6 4.6 

High school 37.3 2.5 38.4 3.2 37.3 2.4 33.4 3.6 39.4 2.4 

Some college 35.3 3.6 31.8 5.8 36.3 4.3 32.2 5.3 30.8 3.2 

College 24.7 3.6 20.1 4.3 21.9 2.7 22.8 4.4 17.8 2.5 

1985 ––––––––––– 

% +CI

1987 ––––––––––– 

 % +CI

1988 ––––––––––– 

 % +CI

1990 ––––––––––– 

 % +CI 

1991 ––––––––––– 

% +CI 

Total	 32.5 1.3 31.1 1.1 30.3 1.0 27.9 1.1 28.7 1.1 

Education§ 

Less than high school 55.1 4.4 60.6 3.7 57.9 3.9 58.4 4.3 59.6 3.8 

High school 37.1 2.1 36.5 1.8 35.7 1.8 34.4 1.8 36.5 2.0 

Some college 28.8 2.7 29.2 2.2 29.2 2.3 24.5 2.1 25.1 2.0 

College 14.9 2.2 15.1 1.7 14.2 1.6 10.9 1.5 11.8 1.5 

1992 ––––––––––– 

% +CI

1993 ––––––––––– 

 % +CI

1994 ––––––––––– 

 % +CI

1995 ––––––––––– 

 % +CI 

Total	 30.7 1.6 29.1 1.4 30.6 1.6 28.2 1.8 

Education§ 

Less than high school 55.5 6.0 60.1 6.2 56.1 7.2 51.7 7.8 

High school 38.3 2.8 38.6 2.7 40.2 2.9 37.0 3.4 

Some college 28.3 2.9 23.4 2.8 27.2 3.2 26.0 3.6 

College 14.3 2.2 11.5 2.0 11.6 2.3 15.3 2.9 

*Data collected before 1978 do not distinguish between whites of Hispanic origin and non-Hispanic whites; 

these data exclude those whites who indicated they were of Hispanic origin. For 1965–1991, current cigarette 

smokers include women aged 18–44 years who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked. For 1992–1995, current smokers include women 

aged 18–44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of 

survey that they currently smoked every day or on some days. 

†

The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977
 

were statistically adjusted to produce estimates that approximate those for white women aged 18–44 years.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

NA = data not available.
 

Source: National Center for Health Statistics, public use data tapes, 1965–1995.
 

106 Chapter 2 
 

 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 43.	 Percentage of white adults who reported being current cigarette smokers,* overall and by gender, 

age, and education, National Health Interview Surveys, United States, 1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 33.5 0.7 30.9 0.6 28.6 0.5 25.9 0.5 26.4 0.6 25.9 0.7 

Gender

 Men 36.8 1.0 32.9 0.8 30.5 0.7 27.6 0.7 27.8 0.8 27.6 0.9

 Women 30.5 0.8 29.0 0.7 26.9 0.6 24.4 0.6 25.0 0.8 24.4 0.8 

Age (years)

 18–34 36.7 1.1 34.6 0.9 32.0 0.8 29.8 0.8 31.6 1.1 31.3 1.2

 35–54 39.0 1.0 35.1 1.0 32.9 0.7 30.0 0.7 29.7 1.0 28.7 1.1 

>55 23.7 0.8 21.9 0.7 19.9 0.7 17.1 0.6 16.7 0.8 16.8 0.9 

Education§

 Less than high school 35.3 1.2 34.4 1.3 34.2 1.1 32.6 1.1 31.9 1.6 33.8 1.7

 High school 35.6 1.1 33.8 0.9 32.6 0.8 30.3 0.7 30.6 1.0 30.3 1.1

 Some college 34.8 1.3 31.2 1.3 28.2 1.0 24.9 0.9 25.4 1.2 24.7 1.3

 College 23.6 1.2 19.0 1.0 16.5 0.7 13.8 0.7 14.2 0.9 13.3 1.0 

*These data exclude whites who indicated they were of Hispanic origin. For 1978–1991, current cigarette 

smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the 

time of survey that they currently smoked. For 1992–1995, current smokers include persons who reported 

smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently 

smoked every day or on some days.

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

Patterns of Tobacco Use 107 
 

<

>25 cigarettes 

<15–24 cigarettes 

>25 cigarettes 

<

>25 cigarettes 

<

>25 cigarettes 

<15–24 cigarettes 

>25 cigarettes 

 

<15–24 cigarettes 

Surgeon General's Report 

Table 44.	 Percentage of adult white smokers* who reported smoking <15, 15–24, or >25 cigarettes per day, 

overall and by gender, age, and education, National Health Interview Surveys, United States, 

1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 

<15 cigarettes 

15–24 cigarettes 

24.0 0.7 25.1 0.8 25.0 0.7 28.9 0.8 32.1 1.1 35.3 1.3 

44.7 0.9 44.9 0.9 44.7 0.8 45.1 0.9 44.0 1.2 43.1 1.4 

31.4 0.9 30.0 0.9 30.3 0.8 26.1 0.9 23.9 1.1 21.6 1.1 

Gender 

Men 

<15 cigarettes 18.9 0.9 19.1 1.2 20.5 1.0 23.2 1.1 26.6 1.6 29.3 1.8 

43.5 1.3 43.7 1.3 42.3 1.1 43.6 1.3 42.3 1.8 43.0 2.0 

37.6 1.3 37.2 1.4 37.3 1.2 33.2 1.3 31.1 1.6 27.7 1.8 

Women 

<15 cigarettes 

15–24 cigarettes 

29.4 1.1 31.3 1.2 29.8 1.0 34.7 1.2 37.7 1.6 41.6 1.9 

45.9 1.3 46.2 1.3 47.2 1.1 46.6 1.2 45.7 1.6 43.2 1.8 

24.7 1.1 22.5 1.1 23.0 0.9 18.7 1.0 16.6 1.2 15.2 1.4 

Age (years) 

18–34 

<15 cigarettes 

15–24 cigarettes 

25.9 1.3 29.6 1.3 29.6 1.2 35.7 1.4 38.3 2.0 43.3 2.2 

47.6 1.2 47.1 1.4 46.7 1.3 46.7 1.5 44.6 1.9 43.4 2.3 

26.5 1.3 23.3 1.2 23.8 1.1 17.6 1.2 17.1 1.5 13.3 1.6 

35–54

<15 cigarettes 18.8 1.0 18.6 1.4 19.1 1.1 22.2 1.1 27.2 1.7 30.3 2.0 

41.4 1.6 41.7 1.7 42.5 1.3 43.4 1.5 43.1 1.8 42.2 2.0 

39.8 1.5 39.7 1.7 38.4 1.3 34.4 1.5 29.7 1.6 27.5 1.8 

>55 

<15 cigarettes 

>25 cigarettes 

28.8 1.7 27.0 1.7 27.0 1.4 29.1 1.6 29.9 2.5 30.5 2.5 

44.2 2.0 45.8 1.8 44.8 1.6 45.4 1.7 44.7 2.7 44.4 2.9 

27.1 1.7 27.2 1.7 28.2 1.5 25.5 1.6 25.4 2.2 25.0 2.7 

*These data exclude those whites who indicated they were of Hispanic origin. For 1978–1991, current cigarette 

smokers include persons who reported smoking at least 100 cigarettes in their lives and who reported at the 

time of survey that they currently smoked. For 1992–1995, current smokers include persons who reported 

smoking at least 100 cigarettes in their lives and who reported at the time of survey that they currently smoked 

every day or on some days. 

108 Chapter 2 
 

<

<

<

<

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 44. Continued 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Education§ 

Less than high school 

<15 cigarettes 22.7 1.4 19.9 1.6 19.5 1.4 20.5 1.6 24.9 2.3 22.8 2.6 

15–24 cigarettes 44.2 1.9 44.8 2.0 44.3 1.7 46.1 1.9 43.5 2.8 45.0 3.3 

>25 cigarettes 33.1 1.6 35.4 1.9 36.1 1.7 33.4 1.9 31.6 2.7 32.2 3.1 

High school 

<15 cigarettes 21.1 1.2 22.4 1.3 21.6 1.0 25.1 1.2 27.4 1.6 29.9 2.0 

15–24 cigarettes 45.1 1.9 45.1 1.5 45.6 1.3 46.8 1.4 46.2 1.9 45.9 2.1 

>25 cigarettes 33.8 1.7 32.5 1.5 32.8 1.2 28.1 1.4 26.4 1.7 24.2 1.9 

Some college 

<15 cigarettes 20.4 1.9 24.3 2.3 25.3 1.6 30.5 1.9 33.8 2.7 38.5 3.2 

15–24 cigarettes 43.5 2.1 43.7 2.5 43.1 2.0 43.5 2.2 43.1 2.8 41.7 3.1 

>25 cigarettes 36.2 2.4 32.0 2.4 31.7 1.7 26.0 1.8 23.1 2.3 19.9 2.5 

College 

<15 cigarettes 28.2 2.8 29.6 2.7 31.7 2.3 35.2 2.4 42.7 3.4 49.7 3.9 

15–24 cigarettes 37.6 2.9 39.2 2.7 39.7 2.3 41.3 2.3 37.6 3.3 35.3 3.8 

>25 cigarettes 34.2 2.5 31.2 2.6 28.6 2.1 23.5 2.2 19.6 2.7 15.0 2.6 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were combined;
 

1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

Patterns of Tobacco Use 109 
 

 

Surgeon General's Report 

Table 45.	 Percentage of adult white ever smokers who have quit,* overall and by gender, age, and 

education, National Health Interview Surveys, United States, 1978–1995 aggregate data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total 40.3 1.1 44.7 0.8 46.9 0.7 50.7 0.7 50.0 0.9 50.7 1.0 

Gender

 Men 45.1 1.2 49.3 1.0 50.8 0.9 54.2 0.9 53.2 1.2 53.3 1.4

 Women 34.1 1.4 39.1 1.0 42.2 0.9 46.6 0.9 46.1 1.3 47.7 1.4 

Age (years)

 18–34 29.6 1.3 31.1 1.1 31.8 1.1 33.5 1.1 29.2 1.5 30.2 1.7

 35–54 39.0 1.3 43.9 1.3 45.3 1.1 48.6 1.1 48.3 1.3 49.0 1.5 

>55 55.4 1.4 60.9 1.2 64.1 1.0 68.9 0.9 69.9 1.3 70.1 1.4 

Education§

 Less than high school 40.3 1.4 44.5 1.8 45.0 1.4 46.9 1.5 49.1 2.1 46.8 2.2

 High school 40.0 1.5 43.5 1.1 44.9 1.1 48.1 1.0 47.6 1.5 47.9 1.6

 Some college 42.9 1.8 47.1 1.8 49.8 1.4 54.5 1.3 54.3 1.8 55.2 2.0

 College 55.0 2.2 61.6 1.7 63.8 1.4 68.2 1.4 66.1 1.9 68.4 2.2 

*These data exclude those whites who indicated they were of Hispanic origin. The prevalence of cessation is the 

percentage of ever smokers who are former smokers. Former smokers are persons who reported smoking at 

least 100 cigarettes in their lives and who reported at the time of survey that they were not current smokers, 

and ever smokers include current and former smokers. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

110 Chapter 2 
 

*These data exclude whites who indicated they were of Hispanic origin. For 1978–1991, current cigarette 

smokers include women aged 18–44 years who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked. For 1992–1995, current smokers include women 

aged 18–44 years who reported smoking at least 100 cigarettes in their lives and who reported at the time of 

survey that they currently smoked every day or on some days. 

†

1978, 1979, and 1980 data were combined; 1983 and 1985 data were combined; 1987 and 1988 data were
 

combined; 1990 and 1991 data were combined; 1992 and 1993 data were combined; and 1994 and 1995 data
 

were combined.
 

‡

95% confidence interval.
 

Source: National Center for Health Statistics, public use data tapes, 1978–1995.
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 46.	 Percentage of white women of reproductive age who reported being current cigarette smokers,* 

overall and by education, National Health Interview Surveys, United States, 1978–1995 aggregate 

data 

1978–1980† 1983–1985† 1987–1988† 1990–1991† 1992–1993† 1994–1995† 

–––––––––– –––––––––– –––––––––– –––––––––– –––––––––– –––––––––– 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI % ±CI % ±CI 

Total	 35.3 1.2 33.7 1.0 30.7 0.8 28.3 0.8 30.0 1.2 29.4 1.2 

Education 

Less than high school 53.4 3.0 54.5 3.4 59.2 2.7 59.0 3.0 57.5 4.2 53.9 5.2 

High school 36.6 1.8 38.0 1.7 36.1 1.4 35.5 1.3 38.5 2.1 38.6 2.3 

Some college 34.2 2.8 29.6 2.1 29.2 1.7 24.8 1.5 26.0 2.1 26.6 2.4 

College 21.7 1.9 16.0 1.6 14.6 1.2 11.4 1.0 13.0 1.4 13.5 1.8 

Patterns of Tobacco Use 111 
 

 ≥55 

Surgeon General's Report 

Appendix 4. Patterns of Cigarette Use Among Among African Americans 

Table 47. Percentage of adult African Americans who reported being current cigarette smokers,* overall and 

by gender, age, and education, National Health Interview Surveys, United States, 1965–1995 

1965 ____________ 

% ±CI‡

1966 ____________ 

 % ±CI

1970 ____________ 

 % ±CI 

1974 ____________ 

Characteristic % ±CI 

Total 45.8 1.5 45.9 1.7 41.4 1.8 44.0 2.2 

Gender 

Men 60.4 2.8 60.1 2.5 52.9 2.0 54.4 3.9 

Women 33.7 2.3 34.2 2.3 32.2 2.5 36.4 2.6 

Age (years) 

18–34 53.2 2.8 52.4 2.9 46.0 2.8 46.2 3.5 

35–54 50.3 3.0 52.6 2.9 47.0 2.2 53.3 3.8 

≥55 27.0 3.2 24.8 3.1 25.1 2.3 28.0 3.8 

Education§ 

Less than high school 44.6 2.4 41.0 2.1 43.3 3.2 

High school 44.6Δ 2.0 51.9 4.6 45.4 3.8 49.1 4.3 

Some college 52.9 7.8 43.0 6.0 37.3 8.6 

College 47.5Δ 5.8 39.6 8.5 34.2 6.4 44.9 9.1 

1985 ____________ 

% ±CI‡

1987 ____________ 

 % ±CI

1988 ____________ 

 % ±CI 

1990 ____________ 

Characteristic % ±CI 

Total 35.0 1.8 32.9 1.6 31.7 1.6 26.2 1.5 

Gender 

Men 39.9 3.0 38.7 2.8 36.6 2.5 32.6 2.4 

Women 31.2 2.2 28.2 1.8 27.8 1.9 21.2 1.6 

Age (years) 

18–34 34.0 2.8 32.6 2.4 31.5 2.4 25.0 2.2 

35–54 42.3 3.4 38.6 2.8 36.0 2.6 32.6 2.7 

27.7 3.0 25.9 2.9 26.4 2.7 19.2 2.4 

Education§ 

Less than high school 39.6 3.0 37.7 2.9 35.0 2.5 30.6 2.8 

High school 39.1 3.4 38.7 2.9 38.8 2.9 31.9 2.5 

Some college 35.0 4.9 34.2 4.0 31.9 3.7 25.7 3.8 

College 28.4 6.1 18.3 3.9 20.9 4.6 17.5 3.8 

*Data collected before 1978 do not distinguish between blacks of Hispanic origin and non-Hispanic blacks; 

these data exclude those African Americans who indicated they were of Hispanic origin. For 1978–1991, 

current cigarette smokers include persons who reported smoking at least 100 cigarettes in their lives and 

who reported at the time of survey that they currently smoked. For 1992–1995, current smokers include 

persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey 

that they currently smoked every day or on some days. 

†The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 

1977 were statistically adjusted to produce estimates for the total population, males, and females that 

approximate those for African Americans aged 18 years and older. Estimates for persons in the 18–34 year 

old age category were statistically adjusted to produce estimates that approximate those for African 

Americans aged 18–34 years old. 

112 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1976†

% ±CI 

 1977†

% ±CI

 1978

 % ±CI

 1979 

 % ±CI 

1980 

% ±CI 

1983 

% ±CI 

40.8 2.1 40.7 2.5 37.5 3.7 37.3 2.4 37.1 3.3 35.8 2.2 

49.3 3.3 47.3 4.0 46.1 5.5 44.5 3.7 44.9 4.4 40.8 3.5 

34.6 3.1 35.9 3.1 31.1 4.5 31.6 2.5 31.0 4.3 31.8 2.6 

44.2 3.1 44.4 3.9 39.1 5.8 38.0 3.2 39.9 4.5 35.8 3.2 

46.9 3.7 46.9 4.2 46.0 6.1 44.4 3.9 40.5 6.9 42.1 4.1 

27.5 3.3 29.9 4.3 24.4 5.2 27.0 4.0 27.5 6.6 27.9 4.2 

38.9 2.8 40.2 3.9 36.7 4.8 37.3 3.6 33.7 6.5 37.4 3.9 

44.5 4.7 48.2 4.9 40.6 5.1 40.5 4.8 47.6 7.2 39.4 4.3 

49.4 7.5 41.8 7.4 46.0 9.9 35.5 6.4 30.8 8.7 34.4 6.3 

36.3 10.3 37.1 8.4 37.3 13.5 36.3 7.5 29.4 8.8 28.4 7.3 

1991 

% ±CI

1992 

 % ±CI

1993 

 % ±CI 

1994 

% ±CI 

1995 

% ±CI 

29.4 1.6 27.8 2.0 26.0 2.0 27.2 2.3 25.8 2.6 

35.5 2.7 32.3 3.5 32.4 3.4 33.9 4.0 28.8 3.7 

24.5 1.9 24.1 2.2 21.0 2.2 21.8 2.2 23.5 3.1 

27.0 2.4 22.4 3.0 21.6 3.3 22.0 3.4 19.9 3.4 

38.3 2.7 38.0 3.7 33.6 3.6 34.7 3.9 33.6 4.6 

20.7 2.7 22.4 3.5 22.3 4.1 24.0 4.0 23.0 3.8 

35.4 3.0 34.4 4.5 33.9 4.5 35.3 4.5 34.1 5.0 

34.9 2.6 32.3 3.7 31.4 3.8 31.6 4.5 31.0 5.0 

31.8 3.8 28.4 4.8 26.6 4.4 27.6 5.4 25.2 5.1 

18.0 4.2 22.4 6.6 13.9 4.6 15.7 5.2 17.6 5.4 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.


ΔLevels presented for 1965 are for persons who had a high school education or less and persons who attended
 

some college or were college graduates.
 

Source: National Center for Health Statistics, public use data tapes, 1965–1995.
 

Patterns of Tobacco Use 113 
 

Table 48.	 Percentage of adult African American smokers* who reported smoking <15, 15–24, or >25 cigarettes 

per day, overall and by gender, age, and education, National Health Interview Surveys, United States, 

1965–1995 

 1965

% ±CI‡

< 15–24 cigarettes 35.5 2.5 36.2 2.5 36.0 2.4 33.0 3.1 

<

<

<

< 15–24 cigarettes 39.9 3.8 39.1 3.7 38.7 3.6 39.4 5.7 

 ≥55 

Surgeon General's Report 

 1966

 % ±CI

 1970

 % ±CI

 1974 

Characteristic % ±CI 

Total 

<15 cigarettes 56.9 2.7 55.8 2.5 55.5 2.5 58.3 3.2 

≥25 cigarettes 7.6 1.4 8.0 1.3 8.6 1.4 8.7 1.8 

Gender 

Men 

<15 cigarettes 49.1 3.3 48.3 3.2 49.6 3.2 52.9 5.0 

15–24 cigarettes 42.0 3.3 41.8 3.1 40.7 3.1 36.5 4.9 

≥25 cigarettes 9.0 1.9 9.9 1.9 9.7 1.7 10.6 2.9 

Women 

<15 cigarettes 68.0 3.7 66.1 3.8 62.8 2.8 64.3 4.0 

15–24 cigarettes 26.3 3.5 28.5 3.5 30.0 2.5 29.1 3.8 

≥25 cigarettes 5.7 1.9 5.5 1.7 7.2 1.7 6.6 2.3 

Age (years) 

18–34 

<15 cigarettes 59.7 4.0 57.3 3.9 58.5 3.2 64.0 3.9 

15–24 cigarettes 33.0 3.7 35.0 4.0 34.0 3.2 27.8 4.0 

≥25 cigarettes 7.4 2.1 7.7 2.1 7.4 2.0 8.2 2.4 

35–54 

<15 cigarettes 51.4 3.9 52.0 3.9 50.7 3.2 49.3 6.2 

≥25 cigarettes 8.7 2.2 8.9 2.3 10.6 2.0 11.3 3.5 

<15 cigarettes 65.2 6.4 63.3 6.9 59.3 5.9 65.3 7.5 

15–24 cigarettes 29.8 6.4 30.6 7.2 34.3 5.6 31.4 8.2 

≥25 cigarettes 5.1 3.0 6.1 3.5 6.5 2.1 3.4 2.6 

Education§ 

Less than high school 

<15 cigarettes NA NA 55.3 3.5 52.5 3.9 55.8 5.5 

15–24 cigarettes NA NA 36.0 3.3 38.0 3.7 35.8 5.3 

≥25 cigarettes NA NA 8.7 2.0 9.5 2.1 8.4 2.6 

High school 

<15 cigarettes 55.8Δ 3.1 50.6 5.7 52.7 4.3 52.9 8.0 

15–24 cigarettes 35.9Δ 3.0 40.4 7.9 37.9 4.4 37.4 6.6 

≥25 cigarettes 8.3Δ 1.8 9.1 3.2 9.4 2.8 9.8 4.1 

Some college 

<15 cigarettes NA NA 59.0 10.4 49.9 10.1 56.4 12.5 

15–24 cigarettes NA NA 32.1 9.4 37.1 8.9 29.5 11.0 

≥25 cigarettes NA NA 9.0 5.8 13.0 6.5 14.1 10.5 

College 

<15 cigarettes 54.6Δ 9.1 60.9 10.1 69.0 11.1 64.8 15.1 

15–24 cigarettes 36.1Δ 8.5 32.3 10.1 23.4 9.7 30.2 14.3 

≥25 cigarettes 9.3Δ 5.3 6.8 5.3 7.6 7.3 5.1 7.1 

*Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic 

African Americans; these data exclude those African Americans who indicated they were of Hispanic origin. 

For 1965–1991, current cigarette smokers include persons who reported smoking at least 100 cigarettes in their 

lives and who reported at the time of survey that they currently smoked. For 1992–1995, current smokers 

include persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of 

survey that they currently smoked every day or on some days. 

†The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 

were statistically adjusted to produce estimates for the total population, males, and females that approximate 

those for African Americans aged 18 years and older. Estimates for persons in the 18–34 year old age category 

were statistically adjusted to produce estimates that approximate those for African Americans aged 18–34 

years old. 

114 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1976†

% ±CI 

 1977†

% ±CI

 1978

 % ±CI

 1979 

 % ±CI

1980 

 % ±CI

1983 

 % ±CI 

52.4 3.9 54.7 4.8 57.0 5.1 55.9 3.2 55.2 5.7 54.9 3.9 

39.0 3.7 35.7 4.4 34.0 4.6 33.3 3.1 33.8 4.8 35.6 3.7

 8.6 2.1 9.8 2.1 9.1 2.8 10.8 1.6 11.0 3.3 9.5 2.4 

44.7 4.7 48.4 5.9 49.5 7.3 51.5 4.9 48.8 9.2 51.4 5.7 

44.2 4.4 35.3 5.2 37.3 6.3 36.3 4.7 38.7 6.8 36.5 5.3 

11.2 3.0 12.6 3.9 13.2 5.1 12.2 2.6 12.5 5.5 12.1 4.1 

60.3 5.8 61.2 6.2 65.0 7.0 60.8 4.4 62.1 6.8 58.5 5.1 

33.8 5.9 36.1 5.6 30.4 6.4 30.0 3.8 28.5 6.3 34.6 5.0

 6.0 2.2 6.9 2.3 4.6 3.0 9.2 2.6 9.4 3.2 6.9 2.5 

56.5 5.5 59.4 5.8 60.3 7.9 60.5 5.2 57.8 6.0 57.7 5.7 

35.9 5.3 34.8 6.3 31.5 7.0 31.1 4.3 33.1 6.3 33.0 5.2

 7.6 2.6 8.0 3.4 8.2 4.2 8.4 2.5 9.1 3.8 9.4 3.7 

44.8 6.5 51.6 7.3 53.0 8.4 48.4 5.1 56.1 10.5 47.6 6.4 

44.0 6.9 35.4 6.2 37.2 7.5 36.2 4.5 32.1 9.2 40.6 6.1 

11.3 3.4 13.0 3.6 9.8 4.8 15.4 4.3 11.8 7.1 11.9 4.4 

57.4 6.4 51.1 8.6 56.1 12.6 59.1 8.7 46.5 11.9 61.7 8.8 

36.9 6.8 40.2 7.5 33.9 12.5 33.3 8.6 38.9 10.6 32.9 8.6

 5.8 3.7 8.7 4.5 10.0 7.2 7.6 4.1 14.7 10.4 5.4 4.0 

50.4 5.8 54.1 7.0 53.4 9.2 52.8 5.7 53.9 9.4 52.8 6.6 

41.2 5.1 35.2 5.6 35.4 8.3 32.9 5.2 32.6 9.1 34.0 6.3

 8.3 3.3 10.7 3.2 11.3 5.4 14.3 4.2 13.6 7.3 13.2 5.1 

48.4 6.9 53.9 7.9 60.4 9.5 53.5 5.6 48.9 9.1 52.6 7.0 

44.3 6.2 34.0 7.4 31.1 9.1 36.1 6.3 35.8 8.1 42.1 6.9

 7.3 3.1 12.1 4.8 8.5 5.5 10.4 4.4 15.3 5.6 5.4 3.1 

54.7 11.7 49.5 12.0 41.5 17.6 57.0 11.5 44.7 18.2 50.2 12.1 

29.2 9.9 42.8 12.7 46.1 16.8 30.1 9.2 42.7 18.5 37.1 11.7 

16.1 7.9 7.7 6.0 12.5 9.0 13.0 6.8 12.5 11.0 12.7 7.9 

44.9 14.9 48.1 15.6 71.9 17.1 47.5 13.2 65.7 18.7 51.6 15.3 

38.8 13.9 37.9 15.6 22.6 12.5 40.1 11.5 31.1 18.3 36.7 14.8 

16.3 13.0 14.0 9.6 5.5 9.8 12.5 9.2 3.3 6.4 11.7 10.9 

‡ 95% confidence interval.
 

§Includes persons aged 25 years and older.


ΔLevels presented for 1965 are for persons who had a high school education or less and persons who attended
 

some college or were college graduates.
 

NA = data not available.
 

Source: National Center for Health Statistics, public use data tapes, 1965–1995.
 

Patterns of Tobacco Use 115 
116 Chapter 2 

 

< 15–24 cigarettes 

< 15–24 cigarettes 

<

<

<

 

<

<

<

<

<

Surgeon General's Report 

Table 48. Continued 

1985 1987 1988 1990 ____________ ____________ ____________ ____________ 

Characteristic % ±CI‡ % ±CI % ±CI % ±CI 

Total 

<15 cigarettes 55.8 3.2 61.2 2.9 56.4 2.7 59.9 3.2 

≥25 cigarettes 

35.0 2.9 31.0 2.8 34.6 2.5 34.2 3.2 

9.3 1.9 7.8 1.6 9.0 1.6 6.0 1.5 

Gender 

Men 

<15 cigarettes 52.8 5.2 55.3 4.2 51.0 4.1 52.6 4.7 

≥25 cigarettes 

36.2 4.3 35.8 4.4 38.2 3.8 40.1 4.7 

11.0 3.2 8.9 2.4 10.8 2.5 7.3 2.3 

Women 

<15 cigarettes 58.7 3.9 67.9 3.5 62.2 3.9 68.8 3.6 

15–24 cigarettes 33.7 3.8 25.7 3.2 30.7 3.6 26.9 3.4 

≥25 cigarettes 7.6 2.0 6.5 1.8 7.2 2.0 4.3 1.7 

Age (years) 

18–34 

<15 cigarettes 56.4 5.4 66.2 4.5 62.1 4.0 67.5 4.9 

15–24 cigarettes 35.4 4.8 27.6 4.0 29.4 3.7 25.8 4.6 

≥25 cigarettes 8.2 3.0 6.2 2.3 8.5 2.4 6.7 2.5 

35–54 

<15 cigarettes 53.1 4.8 54.9 4.6 49.2 4.3 51.9 4.9 

15–24 cigarettes 35.9 4.6 34.9 4.6 40.5 4.4 42.2 4.7 

≥25 cigarettes 11.0 3.0 10.1 2.4 10.3 2.5 5.9 2.2 

≥55 

<15 cigarettes 59.6 6.5 61.5 7.1 56.8 7.3 60.8 6.9 

15–24 cigarettes 

≥25 cigarettes

31.8 6.6 31.8 6.9 35.3 6.7 34.9 6.8 

8.6 4.1 6.7 3.8 7.9 3.4 4.3 2.7 

Education§ 

Less than high school 

<15 cigarettes 57.9 5.0 62.8 4.3 51.4 4.5 54.1 5.8 

15–24 cigarettes 

≥25 cigarettes 

31.8 4.8 27.7 4.5 38.0 4.5 39.2 5.7 

10.3 3.2 9.5 2.9 10.6 3.0 6.7 2.6 

High school 

<15 cigarettes 52.4 5.5 57.6 5.2 58.9 4.7 60.6 5.1 

15–24 cigarettes 39.8 5.4 34.2 4.9 32.3 4.6 34.0 5.0 

≥25 cigarettes 7.9 2.8 8.2 2.9 8.9 2.5 5.4 2.1 

Some college 

<15 cigarettes 47.6 8.9 57.7 7.0 55.0 7.2 57.1 7.8 

15–24 cigarettes 

≥25 cigarettes 

37.6 8.3 35.3 6.7 34.0 6.8 37.6 7.8 

14.8 6.6 7.0 3.9 11.0 4.9 5.4 3.7 

College 

<15 cigarettes 50.5 12.6 56.8 12.1 54.0 13.5 67.9 11.6 

15–24 cigarettes 35.0 11.6 34.7 11.7 40.8 13.5 28.1 11.1 

≥25 cigarettes 14.5 12.8 8.5 5.8 5.2 4.0 4.0 4.0 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1991 

% ±CI 

1992 

% ±CI 

1993 

% ±CI 

1994 

% ±CI 

1995 

% ±CI 

61.2 3.0 61.4 4.3 65.6 4.2 65.3 4.8 62.5 5.2 

30.0 2.8 33.3 3.9 28.5 4.1 27.2 4.3 29.7 4.8 

8.7 1.8 5.3 1.7 6.0 2.1 7.5 3.2 7.8 2.7 

57.5 4.4 55.7 6.8 63.3 6.2 64.1 7.0 57.6 7.4 

31.7 4.0 39.0 6.3 29.2 5.9 25.2 5.8 32.5 7.2 

10.8 2.8 5.3 2.4 7.4 3.4 10.7 5.6 9.9 4.5 

65.7 3.5 67.5 4.9 68.4 5.8 66.7 5.5 69.7 9.7 

28.0 3.4 27.3 4.5 27.5 5.7 29.8 5.5 22.1 8.2

 6.2 1.9 5.2 2.0 4.1 2.2 3.5 1.7 8.2 6.0 

66.9 4.6 68.5 6.6 70.6 7.9 71.5 7.3 68.3 8.5 

27.3 4.4 27.7 6.5 22.8 7.0 22.3 7.0 24.4 8.1

 5.7 2.5 3.8 2.1 6.6 3.8 6.2 3.1 7.2 4.4 

56.7 4.4 59.0 6.0 62.2 6.0 60.6 7.3 57.2 7.3 

32.7 4.0 34.9 5.7 31.2 6.1 31.1 6.4 33.5 7.0 

10.7 2.8 6.1 2.7 6.6 3.2 8.4 5.8 9.4 4.2 

60.0 6.8 54.3 8.8 64.6 10.3 66.2 9.6 67.1 9.1 

29.3 6.5 39.8 8.5 32.0 10.4 26.2 8.4 28.4 8.5 

10.7 4.3 5.9 3.9 3.4 3.6 7.6 6.6 4.5 3.7 

60.0 5.2 56.2 8.2 59.4 8.1 59.3 8.7 52.3 8.6 

28.7 4.8 36.6 8.0 30.9 8.2 32.0 7.9 33.0 8.4 

11.3 3.5 7.2 3.4 9.7 5.0 8.6 6.1 14.8 6.8 

57.6 4.9 61.3 6.1 64.6 6.9 63.9 8.3 64.1 7.9 

35.5 4.8 34.4 5.8 32.1 6.7 28.8 7.2 29.5 7.2

 6.9 2.2 4.3 2.4 3.3 2.7 7.2 6.6 6.4 4.1 

63.8 7.7 62.5 9.2 64.4 10.3 66.9 11.6 58.8 11.7 

28.2 7.4 32.1 9.1 29.8 9.8 27.1 11.3 37.6 11.5

 8.1 4.2 5.4 4.0 5.9 4.8 6.0 4.1 3.6 2.8 

62.4 13.2 72.5 12.6 78.3 17.4 73.3 17.8 83.0 11.1 

22.1 10.8 21.3 11.2 19.4 17.3 26.7 17.8 12.1 9.7

 15.6 11.7 6.1 6.8 2.3 3.6 0.0 0.0 4.9 6.0 

Patterns of Tobacco Use 117 
 

 

 

Surgeon General's Report 

Table 49.	 Percentage of adult African American ever smokers who have quit,* overall and by gender, 

age, and education, National Health Interview Surveys, United States, 1965–1995 

Characteristic 

1965 ____________ 

% ±CI‡

1966 ____________ 

% ±CI

1970 ____________ 

% ±CI 

1974 ____________ 

% ±CI 

Total 15.5 1.7 14.2 1.7 20.6 1.5 19.7 2.4 

Gender 

Men 

Women 

16.1 2.2 15.5 2.2 22.2 2.0 21.7 3.6 

14.5 2.7 12.3 2.4 18.4 2.1 17.4 2.9 

Age (years) 

18–34

35–54 

>55 

8.3 2.0 7.2 1.8 12.8 1.8 13.0 3.9 

16.7 2.6 14.0 2.4 21.1 2.0 16.9 3.3 

29.3 5.2 32.4 5.4 37.4 3.6 38.1 5.8 

Education§ 

Less than high school 

High school 

Some college 

College 

NA NA 17.5 2.3 23.2 2.1 23.3 3.5 

18.2Δ 2.1 11.2 3.5 19.4 3.7 17.4 4.7 

NA NA 12.8 6.5 24.2 6.8 33.2 11.8 

13.2Δ 5.7 19.9 8.6 33.9 9.9 20.4 9.9 

Characteristic 

1985 ____________ 

% ±CI

1987 ____________ 

% ±CI

1988 ____________ 

% ±CI 

1990 ____________ 

% ±CI 

Total 31.3 2.4 31.1 2.4 32.5 2.1 39.0 2.6 

Gender 

Men 

Women 

34.4 3.6 32.9 3.6 34.9 3.1 39.5 3.4 

27.9 3.3 29.0 2.7 29.7 3.0 38.4 3.5 

Age (years) 

18–34 

35–54 

≥55 

21.1 3.5 18.3 3.1 19.2 3.1 24.8 3.9 

30.6 3.7 31.2 3.7 34.9 3.7 39.1 3.8 

48.5 4.6 50.1 4.5 48.3 4.1 58.3 4.6 

Education§ 

Less than high school 

High school 

Some college 

College 

32.8 3.6 34.2 3.7 35.8 3.4 40.4 4.4 

30.8 4.4 27.0 3.7 27.6 3.5 35.7 3.9 

36.6 6.6 35.8 5.5 37.3 5.8 43.8 6.5 

37.4 8.7 49.9 8.2 50.4 8.3 51.4 8.2 

*Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic 

African Americans; these data exclude those African Americans who indicated they were of Hispanic origin. 

The prevalence of cessation is the percentage of ever smokers who are former smokers. Former smokers are 

those who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that 

they were not smoking. 

†

The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and 1977 

were statistically adjusted to produce estimates for the total population, males, and females that approximate 

those for African Americans aged 18 years and older. Estimates for persons in the 18–34 year old age category 

were statistically adjusted to produce estimates that approximate those for African Americans aged 18–34 

years old. 

118 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1976†

____________ 

% ±CI 

1977†

____________ 

% ±CI

 1978 ____________ 

% ±CI

 1979 ____________ 

% ±CI 

1980 ____________ 

% ±CI 

1983 ____________ 

% ±CI 

24.3 2.5 22.7 2.5 26.2 4.1 26.7 2.7 27.5 3.4 28.0 2.9 

26.7 3.4 26.4 4.4 28.5 6.4 28.7 3.8 29.2 4.9 32.0 4.3 

21.6 3.7 18.7 3.0 23.6 4.8 24.4 3.7 25.5 4.9 23.4 3.7 

13.8 3.1 14.3 3.1 17.9 5.6 18.4 4.0 16.9 4.7 18.8 3.9 

24.0 4.7 23.0 4.2 27.3 6.0 26.5 4.9 31.1 7.2 27.7 4.8 

43.4 6.1 37.4 6.2 41.6 10.8 42.8 6.1 41.7 10.0 44.6 6.4 

30.0 3.5 26.9 4.4 29.7 6.1 33.1 4.8 34.7 7.3 32.4 5.1 

23.2 4.9 20.9 4.9 25.4 5.9 25.4 4.2 21.3 9.3 25.4 5.3 

23.7 9.5 26.7 8.3 27.9 13.2 32.7 10.6 37.2 12.9 32.3 9.0 

23.9 13.5 25.3 10.9 20.0 16.2 26.8 9.5 41.9 12.7 36.4 11.8 

1991 ____________ 

% ±CI

1992 ____________ 

% ±CI

1993 ____________ 

% ±CI 

1994 ____________ 

% ±CI 

1995 ____________ 

% ±CI 

33.4 2.6 36.4 3.3 37.8 3.4 34.7 3.5 36.1 3.9 

34.2 3.6 40.1 5.2 37.9 4.8 34.1 5.3 35.9 5.3 

32.4 3.2 31.9 4.0 37.6 4.8 35.3 4.3 36.4 5.3 

17.2 3.6 23.9 7.2 23.3 5.8 16.7 5.6 22.7 6.2 

31.8 3.5 31.3 4.5 35.5 5.1 34.1 5.3 32.1 5.9 

56.4 5.2 57.4 5.4 56.0 6.7 53.8 6.2 55.6 6.1 

35.8 4.5 38.9 5.6 41.2 6.1 34.5 5.6 39.3 5.9 

29.4 3.4 33.5 5.8 33.3 5.4 32.3 6.2 30.8 6.3 

33.0 5.5 37.7 7.6 40.3 7.7 37.6 8.7 37.0 9.2 

51.2 9.1 43.9 11.8 55.1 12.2 50.3 13.0 51.7 11.3 

‡

95% confidence interval.
 

§

Includes persons aged 25 years and older.


ΔLevels presented for 1965 are for persons who had a high school education or less and persons who attended
 

some college or were college graduates.
 

NA = data not available.
 

Source: National Center for Health Statistics, public use data tapes, 1965–1995.
 

Patterns of Tobacco Use 119 
 

Surgeon General's Report 

Table 50.	 Percentage of African American women of reproductive age who reported being current 

cigarette smokers,* overall and by education, National Health Interview Surveys, United 

States, 1965–1995 

1965 ____________ 

% ±CI‡

1966 ____________ 

 % ±CI

1970 ____________ 

 % ±CI 

1974 ____________ 

Characteristic % ±CI 

Total	 42.9 2.9 42.6 2.9 38.6 3.1 41.1 3.5 

Education§ 

Less than high school NA NA 48.1 4.7 45.4 4.6 47.1 7.7 

High school 45.0Δ 4.0 45.9 6.7 38.9 5.4 45.6 6.4 

Some college NA NA 49.6 11.7 36.6 10.4 25.6 12.6 

College 44.7Δ 9.6 42.9 10.9 41.2 9.2 52.7 13.3 

1985 ____________ 

% ±CI

1987 ____________ 

 % ±CI

1988 ____________ 

 % ±CI 

1990 ____________ 

Characteristic	 % ±CI 

Total	 34.0 2.8 31.4 2.5 29.8 2.4 22.7 2.1 

Education§ 

Less than high school 54.3 6.8 49.1 6.0 47.2 6.1 38.2 6.8 

High school 36.9 4.9 35.8 4.3 33.2 4.1 30.7 4.3 

Some college 34.0 7.1 32.4 5.6 28.9 5.0 21.2 4.1 

College 21.3 7.3 19.7 6.5 20.2 6.0 14.9 5.8 

*Data collected before 1978 do not distinguish between African Americans of Hispanic origin and non-Hispanic 

African Americans; these data exclude those African Americans who indicated they were of Hispanic origin. 

For 1965–1991, current cigarette smokers include women aged 18–44 years who reported smoking at least 100 

cigarettes in their lives and who reported at the time of survey that they currently smoked. For 1992–1995, 

current smokers include women aged 18–44 years who reported smoking at least 100 cigarettes in their lives 

and who reported at the time of survey that they currently smoked every day or on some days. 

120 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

1976†

% ±CI 

 1977†

% ±CI

 1978

 % ±CI

 1979 

 % ±CI 

1980 

% ±CI 

1983 

% ±CI 

38.8 4.2 41.7 4.0 36.4 6.3 35.2 3.0 34.6 5.4 34.3 3.4 

45.3 7.1 44.0 9.0 41.5 10.3 43.2 8.9 35.7 12.9 49.6 8.9 

39.1 7.3 49.3 7.6 36.4 7.7 34.5 6.8 40.0 10.0 36.5 6.2 

46.0 9.6 41.4 10.5 53.0 15.3 33.2 9.7 30.5 11.8 29.3 8.4 

35.5 15.4 36.6 15.1 45.9 19.2 36.2 10.3 31.0 17.4 22.5 9.2 

1991 

% ±CI

1992 

 % ±CI

1993 

 % ±CI 

1994 

% ±CI 

1995 

% ±CI 

28.1 2.4 24.5 2.9 23.1 2.9 22.9 1.8 23.8 3.9 

50.4 6.1 45.9 10.0 45.6 9.4 43.6 9.4 49.6 12.3 

32.4 4.0 29.8 5.2 30.2 5.5 26.1 5.2 30.6 6.9 

31.5 5.6 26.1 6.7 26.3 6.5 27.4 8.2 24.9 7.6 

19.8 6.6 18.5 8.2 8.2 6.0 8.0 5.7 13.6 7.9 

†

The 1976 and 1977 surveys collected data only for persons aged 20 years and older. The data for 1976 and
 

1977 were statistically adjusted to produce estimates that approximate those for African American women
 

aged 18–44 years.
 

‡

95% confidence interval.
 

§ Includes persons aged 25 years and older.
 

ΔLevels presented for 1965 are for persons who had a high school education or less and persons who attended
 

some college or were college graduates.
 

NA = data not available.
 

Source: National Center for Health Statistics, public use data tapes, 1965–1995.
 

Patterns of Tobacco Use 121 
122 Chapter 2 

__________________ _________________ _________________ _____________ 

>HS >HS

Surgeon General's Report 

Appendix 5. Validation of the Retrospective Assessment of 

Smoking Prevalence 

Because the method of computing smoking 

prevalences retrospectively is inherent in the birth cohort analyses described in this chapter, comparability 

of these estimates with accepted cross-sectional 

estimates was examined. At least two factors contribute to the observed difference between retrospective 

and cross-sectional estimates of smoking prevalence: 

how a former smoker is defined and differences in mortality between smokers and nonsmokers (differential 

mortality). Retrospective estimates will be greater than 

cross-sectional ones because they are based on the age 

at which a smoker quits once and for all. However, crosssectional estimates, using the accepted definition of a 

former smoker (a person who has ever smoked 100 

cigarettes but does not smoke now), classify ever smokers who are not currently smoking as quitters, even 

though many will relapse several times before finally 

quitting. Differential mortality results in retrospective 

estimates smaller than cross-sectional ones because 

smokers are less likely than others to survive and report their smoking history. This factor affects only 

the older birth cohorts (Harris 1983). 

Retrospective estimates of smoking prevalence 

were assessed by comparing them with smoking 

prevalence estimates from the NHISs from 1965 

through 1988 and from Gallup surveys from 1944 

through 1988. The NHIS and Gallup surveys both 

sample adults only; thus, for the comparison, retrospective prevalences computed for each year included 

only respondents aged 18 years and older in that calendar year. Sample sizes for the birth cohorts included in this analysis varied widely (Table 51) 

(NCHS, public use data tapes, 1978, 1979, 1980, 

1982–1984 [HHANES], and 1987 and 1988 combined). 

When this methodology was used to estimate 

smoking prevalences retrospectively for the national 

Table 51.	 Sample sizes for birth cohorts, by gender, race/ethnicity, and education,* National Health 

Interview Surveys, 1978–1980, 1987 and 1988 combined, and Hispanic Health and Nutrition 

Examination Survey, 1982–1984

 Men 

______ Women __________

African American Hispanic African American Hispanic 

Birth Cohort <HS <HS <HS >HS <HS >HS 

1908–1917 401 96 142 33 601 185 229 30 

1918–1927 494 222 267 111 683 444 376 113 

1928–1937 370 387 387 178 531 638 508 233 

1938–1947 292 622 266 226 457 1,013 392 277 

1948–1957 277 1,066 322 375 555 2,006 417 462 

1958–1967† 175 755 180 255 415 1,510 224 319 

*Education was identified as either <12 years of school completed (<HS [high school]) or ≥12 years of school 

completed (≥HS).

†

The smoking experience of this cohort is still incomplete.
 

Source: National Center for Health Statistics, public use data tapes, 1978, 1979, 1980, 1982–1984 (Cancer
 

Control Supplement and Epidemiology Supplement), and 1987 and 1988 combined.
 
 

Percentage 

80 

70 

60 

50 National 

Health 

Interview 

40 Surveys 

(NHISs) 

30 Gallup polls 

Current 

Population 

Survey (CPS)

10 

Reconstructed 

NHISs 

20 

0
 

1910 1920 1930 1940 1950 1960 1970 1980 1990
 

Year 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

samples of the combined 1978, 1979, 1980, 1987, and 

1988 NHISs, the prevalence of smoking in the U.S. 

population was estimated at approximately 10 percent 

in 1910, and it gradually increased before peaking in 

1960 at approximately 50 percent (Figure 16). The 

prevalence then declined gradually to 28 percent in 

1988. 

Data from successive Gallup polls administered 

since 1944 show a somewhat lower smoking prevalence than do retrospective estimates, especially between 1956 and 1970. Both the NHIS and the Gallup 

poll estimates follow a similar trend. For most years, 

retrospective estimates are slightly higher than those 

estimated from cross-sectional surveys (Table 52) 

(NCHS, public use data tapes, 1978, 1979, 1980, 

1982–1984 [HHANES], and 1987 and 1988 combined). 

In addition, the estimate for the 1955 CPS (37.6 percent) is slightly lower than that estimated from the retrospective NHIS estimates (Figure 16). These findings 

are probably accounted for by the surveys’ differing 

definitions of former smoker. 

The overall agreement of the retrospective 

prevalences with cross-sectional NHIS and Gallup poll 

data supports the validity of the prevalence estimates 

among successive birth cohorts for the population subgroups presented in this chapter. 

Figure 16. Comparison of smoking prevalence estimates from selected U.S. surveys, 1910–1991 

Sources: Reconstructed estimates for 1910–1988 from the 1987–1988 combined NHISs (National Center for 

Health Statistics [NCHS], public use data tapes, 1987–1988); 1944–1991 Gallup polls (Thomas and Larsen 

1993); 1955 CPS (USDHHS 1988); and 1965–1991 NHISs (NCHS, public use data tapes, 1965–1991). 

Patterns of Tobacco Use 123 
 

Surgeon General's Report 

Table 52.	 Comparison of current smoking prevalence* (%) between reconstructed estimates from National 

Health Interview Surveys (NHISs), 1987 and 1988 combined, NHIS cross-sectional survey 

estimates, and Gallup poll estimates 

Reconstructed NHISs Cross-sectional NHISs Gallup Polls _____________________ ________________________ ________________________ 

Year Estimate Estimate Difference† Estimate Difference† 

1944 42.7 NA NA 41 –1.7 

1949 45.4 NA NA 44 –1.4 

1954 46.7 NA NA 45 –1.7 

1957 46.7 NA NA 42 –4.7 

1965 45.8 42.4 –3.4 NA NA 

1966 45.3 42.6 –2.7 NA NA 

1969 43.2 NA NA 40 –3.2 

1970 42.7 37.4 –5.3 NA NA 

1971 42.3 NA NA 42 –0.3 

1972 41.5 NA NA 43 +1.5 

1974 40.8 37.1 –3.7 40 –0.8 

1976 39.9 36.4 –3.5 NA NA 

1977 39.2 36.0 –3.2 38 –1.2 

1978 38.5 34.1 –4.4 36 –2.5 

1979 38.0 33.5 –4.5 NA NA 

1980 37.4 33.2 –4.2 NA NA 

1981 36.7 NA NA 35 –1.7 

1983 34.4 32.1 –2.3 38 +3.6 

1985 32.1 30.1 –2.0 35 +2.9 

1986 30.5 NA NA 31 +0.5 

1987 29.2 28.8 –0.4 30 +0.8 

1988 28.2 28.1 –0.1 32 +3.8 

*In the NHIS, current smokers are persons who reported smoking at least 100 cigarettes in their lives and who 

reported at the time of survey that they currently smoked; in the Gallup poll, current smokers are persons who 

reported at the time of poll that they had smoked any cigarettes in the past week. 

†Difference between the survey estimate and the reconstructed prevalence estimate.
 

NA = data not available.
 

Sources: National Center for Health Statistics, public use data tapes, 1965, 1966, 1970, 1974, 1976, 1977, 1978,
 

1979, 1980, 1983, 1985, and 1987 and 1988 combined; Gallup and Newport 1990.
 

124 Chapter 2 
 

 

 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

References 

Andreski P, Breslau N. Smoking and nicotine 

dependence in young adults: differences between 

blacks and whites. Drug and Alcohol Dependence 1993; 

32(2):11–925. 

Austin GA, Prendergast ML, Lee H. Substance Abuse 

Among Asian American Youth: Prevention Research Update 1989;5(Winter):1–29. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1976. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1980a. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1978. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1980b. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1980. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1981. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1982. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1984. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1984. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1985. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1986. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1987. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1988. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1991a. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1990. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1993a. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1992. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1993b. 

Bachman JG, Johnston LD, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1994. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1997. 

Bachman JG, Wallace JM Jr, O’Malley PM, Johnston 

LD, Kurth CL, Neighbors HW. Racial/ethnic differences in smoking, drinking, and illicit drug use among 

American high school seniors, 1976–89. American Journal of Public Health 1991b;81(3):372–7. 

Backinger CL, Bruerd B, Kinney MB, Szpunar SM. 

Knowledge, intent to use, and use of smokeless tobacco 

among sixth grade schoolchildren in six selected U.S. 

sites. Public Health Reports 1993;108(5):637–42. 

Bauman KE, Ennett SE. Tobacco use by black and white 

adolescents: the validity of self-reports. American Journal of Public Health 1994;84(3):394–8. 

Bauman KE, Koch GG, Fisher LA, Bryan ES. Use of 

smokeless tobacco by age, race, and gender in ten standard metropolitan statistical areas of the Southeast 

United States. In: National Cancer Institute. Smokeless 

Tobacco Use in the United States. National Cancer Institute Monograph No. 8. Bethesda (MD): US Department 

of Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute, Division of Cancer Prevention and Control, Smoking, Tobacco, and Cancer Program. NIH Publication 

No. 89-3055, 1989:35–7. 

Benowitz NL, Pérez-Stable E, Herrera B, Jacob P. African American-Caucasian differences in nicotine and 

cotinine metabolism [abstract]. Clinical Pharmacology 

and Therapeutics 1995;57(2):159. 

Patterns of Tobacco Use 125 
 

Surgeon General's Report 

Blaisdell RK. The health status of the Kanaka Maoli. 

Asian American and Pacific Islander Journal of Health 

1993;1(2):116–60. 

Blum RW, Harmon B, Harris L, Bergeisen L, Resnick 

MD. American Indian-Alaska Native youth health. 

Journal of the American Medical Association 1992;267 

(12):1637–44. 

Bruerd B. Smokeless tobacco use among Native 

American children. Public Health Reports 1990;105 

(2):196–201. 

Burns D, Pierce JP. Tobacco Use in California, 1990–1991. 

Sacramento (CA): California Department of Health 

Services, 1992. 

Camp DE, Klesges RC, Relyea G. The relationship between body weight concerns and adolescent smoking. 

Health Psychology 1993;12(1):24–32. 

Centers for Disease Control. Oneida Indian Nation of 

New York Health Needs Assessment 1990. Atlanta: US 

Department of Health and Human Services, Public 

Health Service, Centers for Disease Control, 1990. 

Centers for Disease Control. Cigarette smoking among 

reproductive-aged women—Behavioral Risk Factor 

Surveillance System, 1989. Morbidity and Mortality 

Weekly Report 1991a;40(42):719–23. 

Centers for Disease Control. Cigarette smoking among 

youth—United States, 1989. Morbidity and Mortality 

Weekly Report 1991b;40(41):712–5. 

Centers for Disease Control. Differences in the age 

of smoking initiation between blacks and whites— 

United States. Morbidity and Mortality Weekly Report 

1991c;40(44):754–7. 

Centers for Disease Control. Cigarette smoking among 

American Indians and Alaskan Natives—Behavioral 

Risk Factor Surveillance System, 1987–1991. Morbidity 

and Mortality Weekly Report 1992a;41(45):861–3. 

Centers for Disease Control. Cigarette smoking among 

Chinese, Vietnamese, and Hispanics—California, 

1989–1991. Morbidity and Mortality Weekly Report 

1992b;41(20):362–7. 

Centers for Disease Control. Cigarette smoking among 

Southeast Asian immigrants—Washington State, 1989. 

Morbidity and Mortality Weekly Report 1992c;41(45): 

854–61. 

Centers for Disease Control. Comparison of the 

cigarette brand preferences of adult and teenaged 

smokers—United States, 1989, and 10 U.S. communities, 1988 and 1990. Morbidity and Mortality Weekly 

Report 1992d;41(10):169–73, 179–81. 

Centers for Disease Control. Using Chronic Disease Data: 

A Handbook for Public Health Practitioners. Atlanta: US 

Department of Health and Human Services, Public 

Health Service, Centers for Disease Control, National 

Center for Chronic Disease Prevention and Health Promotion, Office of Surveillance and Analysis, 1992e. 

Centers for Disease Control and Prevention. Smoking 

cessation during previous year among adults—United 

States, 1990 and 1991. Morbidity and Mortality Weekly 

Report 1993:42(26):504–7. 

Centers for Disease Control and Prevention. Changes 

in the cigarette brand preferences of adolescent 

smokers—United States, 1989–1993. Morbidity and Mortality Weekly Report 1994a;43(32):577–81. 

Centers for Disease Control and Prevention. Cigarette 

smoking among women of reproductive age—United 

States, 1987–1992. Morbidity and Mortality Weekly 

Report 1994b;43(43):789–91, 797. 

Centers for Disease Control and Prevention. Surveillance for selected tobacco-use behaviors—United 

States, 1900–1994. Morbidity and Mortality Weekly 

Report 1994c;43(SS-3):1–43. 

Centers for Disease Control and Prevention. Smokeless tobacco use among American Indian women— 

Southeastern North Carolina, 1991. Morbidity and 

Mortality Weekly Report 1995;44(6):113–7. 

Centers for Disease Control and Prevention. Tobacco 

use and usual source of cigarettes among high school 

students—United States, 1995. Morbidity and Mortality 

Weekly Report 1996;45(20):413–8. 

Centers for Disease Control and Prevention. Behavioral Risk Factor Survey of Korean Americans— 

Alameda County, California, 1994. Morbidity and 

Mortality Weekly Report 1997a;46(33):774–7. 

Centers for Disease Control and Prevention. Cigar 

smoking among teenagers—United States, Massachusetts, and New York, 1996. Morbidity and Mortality 

Weekly Report 1997b;46(20):433–40. 

126 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Chandra A. Health Aspects of Pregnancy and Childbirth: United States, 1982–88. Vital and Health Statistics. 

Series 23, No. 18. Hyattsville (MD): US Department of 

Health and Human Services, Public Health Service, 

Centers for Disease Control and Prevention, National 

Center for Health Statistics. DHHS Publication No. 

(PHS) 95-1994, 1995. 

Chen VW. Smoking and the health gap in minorities. 

Annals of Epidemiology 1993;3(2):159–64. 

Clark PI, Gautam S, Gerson LW. Effect of menthol cigarettes on biochemical markers of smoke exposure 

among black and white smokers. Chest 1996;110(5): 

1194–8. 

Crawford FG, Mayer J, Santella RM, Cooper TB, 

Ottman R, Tsai WY, et al. Biomarkers of environmental tobacco smoke in preschool children and their mothers. Journal of the National Cancer Institute 1994;86(18): 

1398–402. 

Cummings KM, Giovino G, Mendicino AJ. Cigarette 

advertising and black-white differences in brand preferences. Public Health Reports 1987;102(6):698–701. 

Davis RL, Helgerson SD, Waller P. Smoking during 

pregnancy among Northwest Native Americans. Public Health Reports 1992;107(1):66-9. 

Delgado JL, Johnson CL, Roy I, Treviño FM. Hispanic 

Health and Nutrition Examination Survey: Methodological Considerations. American Journal of Public 

Health 1990;80(Suppl):6–10. 

Dusenbury L, Kerner JF, Baker E, Botvin G, JamesOrtiz S, Zauber A. Predictors of smoking prevalence 

among New York Latino youth. American Journal of 

Public Health 1992;82(1):55–8. 

Escobedo LG, Anda RF, Smith PF, Remington PL, Mast 

EE. Sociodemographic characteristics of cigarette 

smoking initiation in the United States: implications 

for smoking prevention policy. Journal of the American 

Medical Association 1990;264(12):1550–5. 

Escobedo LG, Peddicord JP. Smoking prevalence in US 

birth cohorts: the influence of gender and education. 

American Journal of Public Health 1996;86(2):231–6. 

Escobedo LG, Reddy M, DuRant RH. Relationship 

between cigarette smoking and health risk and problem behaviors among US adolescents. Archives of Pediatrics and Adolescent Medicine 1997;151(1):66–71. 

Escobedo LG, Remington PL. Birth cohort analysis of 

prevalence of cigarette smoking among Hispanics in 

the United States. Journal of the American Medical Association 1989;261(1):66–9. 

Escobedo LG, Remington PL, Anda RF. Long-term 

age-specific prevalence of cigarette smoking among 

Hispanics in the United States. Journal of Psychoactive 

Drugs 1989a;21(3):307–18. 

Escobedo LG, Remington PL, Anda RF. Long-term 

secular trends in initiation of cigarette smoking among 

Hispanics in the United States. Public Health Reports 

1989b;104(6):583–7. 

Escobedo LG, Zhu BP, Giovino GA, Eriksen MP. Educational attainment and racial differences in cigarette 

smoking. Journal of the National Cancer Institute 1995; 

87(20):1552–3. 

Etzel RA, Jones DB, Schlife CM, Lyke JR, Spierto FW, 

Middaugh JP. Passive smoking and tobacco chewing 

among Alaskan children: measuring saliva cotinine. 

Journal of Smoking-Related Diseases 1992;3(2):161–5. 

Faulkner DL, Escobedo LG, Zhu BP, Chrismon JH, 

Merritt RK. Race and the incidence of cigarette smoking among adolescents in the United States. Journal of 

the National Cancer Institute 1996;88(16):1158–60. 

Fiore MC, Novotny TE, Pierce JP, Hatziandreu EJ, Patel 

KM, Davis RM. Trends in cigarette smoking in the 

United States: the changing influence of gender and 

race. Journal of the American Medical Association 

1989;261(1):49–55. 

Flay BR, Brannon BR, Johnson CA, Hansen WB, Ulene 

AL, Whitney-Saltiel DA, et al. The Television School 

and Family Smoking Prevention and Cessation Project. 

Preventive Medicine 1988;17(5):585–607. 

Floyd RL, Rimer BK, Giovino GA, Mullen PD, Sullivan 

SE. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annual Review 

of Public Health 1993;14:379–411. 

Gallup G Jr, Newport F. Many Americans favor restrictions on smoking in public places. The Gallup Poll 

Monthly 1990;298(July):19–27. 

Patterns of Tobacco Use 127 
 

Surgeon General's Report 

Gentry EM, Kalsbeek WD, Hogelin GC, Jones JT, 

Gaines KL, Forman MR, et al. The Behavioral Risk 

Factor Surveys: II. Design, methods, and estimates 

from combined state data. American Journal of Preventive Medicine 1985;1(6):9–14. 

Goldberg HI, Warren CW, Oge LL, Friedman JS, 

Helgerson SD, Pepion DD, et al. Prevalence of behavioral risk factors in two American Indian populations 

in Montana. American Journal of Preventive Medicine 

1991;7(3):155–60. 

Gong YL, Koplan JP, Feng W, Chen CHC, Zheng P, 

Harris JR. Cigarette Smoking in China: prevalence, 

characteristics, and attitudes in Minhang district. 

Journal of the American Medical Association 1995; 

274(15):1232–4. 

Greenlund KJ, Johnson C, Wattigney W, Bao W, Webber 

LS, Berenson GS, et al. Trends in cigarette smoking 

among children in a southern community, 1976–1994: 

the Bogalusa Heart Study. Annals of Epidemiology 

1996;6(6):476–482. 

Guendelman S, Abrams B. Dietary, alcohol, and tobacco intake among Mexican-American women of 

childbearing age: results from HANES data. American 

Journal of Health Promotion 1994;8(5):363–72. 

Harris JE. Cigarette smoking among successive birth 

cohorts of men and women in the United States during 1900-80. Journal of the National Cancer Institute 1983; 

71(3):473–9. 

Hawks BL. Smoking and smoking-related cancers 

among Asian and Pacific Islander Americans. In: Jones 

LA, editor. Minorities and Cancer. New York: SpringerVerlag, 1989:137–51. 

Haynes SG, Harvey C, Montes H, Nickens H, Cohen 

BH. VIII. Patterns of cigarette smoking among 

Hispanics in the United States: results from HHANES 

1982–84. American Journal of Public Health 1990;80 

(Suppl):47–54. 

Hodge FS, Cummings S, Fredericks L, Kipnis P, Williams M, Teehee K. Prevalence of smoking among adult 

American Indian clinic users in northern California. 

Preventive Medicine 1995;24(5):441–6. 

Hunter SM, Croft JB, Burke GL, Parker FC, Webber 

LS, Berenson GS. Longitudinal patterns of cigarette 

smoking and smokeless tobacco use in youth: the 

Bogalusa Heart Study. American Journal of Public Health 

1986;76(2):193–5. 

Husten CG, McCarty MC, Giovino GA, Chrismon JH, 

Zhu B-P. Intermittent smokers: a descriptive analysis 

of persons who have never smoked daily. American 

Journal of Public Health 1998;88(1):86–9. 

Hymowitz N, Sexton M, Ockene J, Grandits G. Baseline 

factors associated with smoking cessation and relapse. 

Preventive Medicine 1991;20(5):590–601. 

Hymowitz N, Mouton C, Edkholdt H. Menthol cigarette smoking in African Americans and whites [letter]. Tobacco Control 1995;4(2):194–5. 

Jenkins CNH, McPhee SJ, Bird JA, Bonilla N-TH. Cancer risks and prevention practices among Vietnamese 

refugees. Western Journal of Medicine 1990;153(1):34–9. 

Jenkins CNH, Dai PX, Ngoc DH, Kinh HV, Hoang TT, 

Bales S, et al. Tobacco use in Vietnam: prevalence, predictors, and the role of the transnational tobacco corporations. Journal of the American Medical Association 

1997a;277(21):1726–31. 

Jenkins CNH, McPhee SJ, Le A, Pham GQ, Ha N-T, 

Stewart S. The effectiveness of a media-led intervention to reduce smoking among Vietnamese-American 

men. American Journal of Public Health 1997b;87(6): 

1031–4. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1977. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1980a. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1979. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1980b. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1981. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1982. 

128 Chapter 2 
 

 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1983. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1984. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1985. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1986. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1987. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1991. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1989. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1992. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1991. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1993a. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1993. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1995a. 

Johnston LD, Bachman JG, O’Malley PM. Monitoring 

the Future: Questionnaire Responses from the Nation’s High 

School Seniors, 1995. Ann Arbor (MI): Survey Research 

Center, Institute for Social Research, University of 

Michigan, 1997. 

Johnston LD, O’Malley PM, Bachman JG. National Survey Results on Drug Use from Monitoring the Future Study, 

1975–1992: Volume 1, Secondary School Students. 

Rockville (MD): US Department of Health and Human 

Services, Public Health Service, National Institutes of 

Health, National Institute on Drug Abuse. NIH Publication No. 93-3597, 1993b. 

Johnston LD, O’Malley PM, Bachman JG. National Survey Results on Drug Use from Monitoring the Future Study, 

1975–1994: Volume 1, Secondary School Students. 

Rockville (MD): US Department of Health and Human 

Services, Public Health Service, National Institutes of 

Health, National Institute on Drug Abuse. NIH Publication No. 95-4026, 1995b. 

Johnston LD, O’Malley PM, Bachman JG. National Survey Results on Drug Use from the Monitoring the Future 

Study, 1975–1995: Volume 1, Secondary School Students. 

Rockville (MD): US Department of Health and Human 

Services, Public Health Service, National Institutes of 

Health, National Institute on Drug Abuse. NIH Publication No. 96-4139, 1996. 

Kimball EH, Goldberg HI, Oberle MW. Western Washington Native American Behavioral Risk Factor Survey, 

1989, Final Report. Washington (DC): Chehalis, Hoh, 

Quinault, and Shoalwater Bay Indian Tribes, Indian 

Health Service, Centers for Disease Control, University of Washington School of Public Health and Community Medicine, reprinted by the US Department of 

Health and Human Services, Public Health Service, 

1990. 

Klatsky AL, Armstrong MA. Cardiovascular risk factors among Asian Americans living in northern California. American Journal of Public Health 1991;81(11): 

1423–8. 

Kleinman JC, Kopstein A. Smoking during pregnancy, 

1967–80. American Journal of Public Health 1987; 

77(7):823–5. 

Knight JM, Eliopoulos C, Klein J, Greenwald M, Koren 

G. Passive smoking in children: racial differences in 

systemic exposure to cotinine by hair and urine analysis. Chest 1996;109(2):446–50. 

Koepke D, Flay BR, Johnson CA. Health behaviors in 

minority families: the case of cigarette smoking. Family and Community Health 1990;13(1):35–43. 

Kolbe LJ. An epidemiological surveillance system to 

monitor the prevalence of youth behaviors that most 

affect health. Health Education 1990;21(6):44–8. 

Kolbe LJ, Kann L, Collins JL. Overview of the Youth 

Risk Behavior Surveillance System. Public Health Reports 1993;108(1 Supp1):2–10. 

Patterns of Tobacco Use 129 
 

Surgeon General's Report 

Kominski R, Adams A. Educational Attainment in the 

United States: March 1993 and 1992. Washington (DC): 

US Government Printing Office. Current Population 

Reports, P20–476, 1994. 

Koong SL, Malison MD, Nakashima AK. A prevalence 

survey of behavioural risk factors in Taipei City, Taiwan. International Journal of Epidemiology 1990;19 

(1):154–9. 

Kopstein AN, Roth PT. Drug Abuse Among Racial/Ethnic Groups. Rockville (MD): US Department of Health 

and Human Services, Public Health Service, National 

Institutes of Health, National Institute on Drug Abuse, 

1993. 

Lando HA, Johnson KM, Graham-Tomasi RP, 

McGovern PG, Solberg L. Urban Indians’ smoking 

patterns and interest in quitting. Public Health Reports 

1992;107(3):340–4. 

Lefkowitz D, Underwood C. Personal Health Practices: 

Findings from the Survey of American Indians and Alaska 

Natives. National Medical Expenditure Survey Research Findings 10. Rockville (MD): US Department 

of Health and Human Services, Public Health Service, 

Agency for Health Care Policy and Research. AHCPR 

Publication No. 91-0034, 1991. 

Leonard B, Paisano R, Smith EM, Kileen MJ, Cobb N. 

IHS Tobacco Project. The IHS Primary Care Provider 

1993;18(6):107–16. 

Li VC, Hu J-H, Zhou M, Zheng J. Behavioral aspects 

of cigarette smoking among industrial college men of 

Shanghai, China. American Journal of Public Health 

1988;78(12):1550–3. 

Liberatos P, Link BG, Kelsey JL. The measurement of 

social class in epidemiology. Epidemiologic Reviews. Vol. 

10. Baltimore (MD): The Johns Hopkins University 

School of Hygiene and Public Health, 1988:87–121. 

Lovato CY, Litrownik AJ, Elder J, Nuñez-Liriano A, 

Suarez D, Talavera GA. Cigarette and alcohol use 

among migrant Hispanic adolescents. Family & Community Health 1994;16(4):23–36. 

Lowry R, Kann L, Collins JL, Kolbe LJ. The effect of 

socioeconomic status on chronic disease risk behaviors among US adolescents. Journal of the American 

Medical Association 1996;276(10):792–7. 

Marcus AC, Crane LA, Shopland DR, Lynn WR. Use of 

smokeless tobacco in the United States: recent estimates 

from the Current Population Survey. In: National Cancer Institute. Smokeless Tobacco Use in the United States. 

National Cancer Institute Monograph No. 8. Bethesda 

(MD): US Department of Health and Human Services, 

Public Health Service, National Institutes of Health, 

National Cancer Institute, Division of Cancer Prevention and Control, Smoking, Tobacco, and Cancer Program. NIH Publication No. 89-3055, 1989:17–23. 

McIntosh H. Black teens not smoking in great numbers. Journal of the National Cancer Institute 1995; 

87(8):564. 

McPhee SJ, Jenkins CNH, Anh L. Smoking Prevention 

and Cessation Among Vietnamese in Northern California: 

Final Report. Sacramento (CA): Report submitted to the 

Tobacco Control Section, Department of Health Services, State of California, 1993. 

McPhee SJ, Jenkins CNH, Wong C, Fordham D, Lai 

KQ, Bird JA, Moskowitz JM. Smoking cessation intervention among Vietnamese Americans: a controlled 

trial. Tobacco Control 1995;4(Suppl 1):16S–24S. 

Mermelstein R, Robinson R, Ericksen M, Crosset L, 

Feldman S. Explanations of race and gender differences 

in teen tobacco use. Paper presented at the 124th annual meeting of the American Public Health Association, New York City, November 19, 1996. 

Montgomery LE, Carter-Pokras O. Health status by 

social class and/or minority status: implications for 

environmental equity research. Toxicology and Industrial Health 1993;9(5):729–73. 

Moss AJ, Allen KF, Giovino GA, Mills SL. Recent 

Trends in Adolescent Smoking, Smoking-Uptake Correlates, and Expectations About the Future. Advance 

Data. No. 221. Hyattsville (MD): US Department of 

Health and Human Services, Public Health Service, 

Centers for Disease Control and Prevention, National 

Center for Health Statistics. DHHS Publication No. 

(PHS) 93-1250, 1992. 

National Cancer Institute. Strategies to Control Tobacco 

Use in the United States: A Blueprint for Public Health 

Action in the 1990’s. Smoking and Tobacco Control 

Monograph No. 1. Bethesda (MD): US Department of 

Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute. NIH Publication No. 92-3316, 1991. 

130 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

National Center for Health Statistics. Health Interview 

Survey Procedure, 1957–1974. Vital and Health Statistics. Series 1, No. 11. Rockville (MD): US Department 

of Health, Education, and Welfare, Public Health Service, Health Resources Administration, National Center for Health Statistics. DHEW Publication No. (HRA) 

75-1311, 1975. 

National Center for Health Statistics. The National 

Health Interview Survey Design, 1973–84, and Procedures, 1975–83. Vital and Health Statistics. Series 1, No. 

18. Hyattsville (MD): US Department of Health and 

Human Services, Public Health Service, National Center for Health Statistics. DHHS Publication No. (PHS) 

85-1320, 1985a. 

National Center for Health Statistics. Plan and Operation of the Hispanic Health and Nutrition Examination Survey, 1982–84. Vital and Health Statistics. Series 

1, No. 19. Hyattsville (MD): US Department of Health 

and Human Services, Public Health Service, National 

Center for Health Statistics. DHHS Publication No. 

(PHS) 85-1321, 1985b. 

National Center for Health Statistics. Design and Estimation for the National Health Interview Survey, 1985– 

94. Vital and Health Statistics. Series 2, No. 110. 

Hyattsville (MD): US Department of Health and Human Services, Public Health Service, National Center 

for Health Statistics. DHHS Publication No. (PHS) 89­

1384, 1989. 

National Center for Health Statistics. Advance Report 

on New Data from the 1989 Birth Certificate. Monthly 

Vital Statistics Report 1992;40(12 Suppl). 

National Center for Health Statistics. Advance Report 

of Maternal and Infant Health Data from the Birth 

Certificate, 1990. Monthly Vital Statistics Report 

1993;42(2 Suppl). 

National Center for Health Statistics. Advance Report 

of Maternal and Infant Health Data from the Birth 

Certificate, 1991. Monthly Vital Statistics Report 

1994;42(11 Suppl). 

National Center for Health Statistics. Health, United 

States, 1995. Hyattsville (MD): Public Health Service. 

DHHS Publication No. (PHS) 96-1232, 1996. 

National Institute on Drug Abuse. Summary Tables: 

Annualized Estimates from the National Pregnancy and 

Health Survey. Rockville (MD): US Department of 

Health and Human Services, Public Health Service, 

National Institutes of Health, National Institute on 

Drug Abuse, 1994. 

Navarro AM. Cigarette smoking among adult Latinos: 

the California Tobacco Baseline Survey. Annals of Behavioral Medicine 1996;18(4)238–45. 

Nelson DE, Giovino GA, Shopland DR, Mowery PD, 

Mills SL, Eriksen MP. Trends in cigarette smoking 

among US adolescents, 1974 through 1991. American 

Journal of Public Health 1995;85(1):34–40. 

Novotny TE, Pierce JP, Fiore MC, Davis RM. Smokeless tobacco use in the United States: the Adult Use of 

Tobacco Surveys. In: National Cancer Institute. Smokeless Tobacco Use in the United States. National Cancer 

Institute Monograph No. 8. Bethesda (MD): US Department of Health and Human Services, Public Health 

Service, National Institutes of Health, National Cancer Institute, Division of Cancer Prevention and Control, Smoking, Tobacco, and Cancer Program. NIH 

Publication No. 89-3055, 1989:25–8. 

Novotny TE, Warner KE, Kendrick JS, Remington PL. 

Smoking by blacks and whites: socioeconomic and 

demographic differences. American Journal of Public 

Health 1988;78(9):1187–9. 

Overpeck MD, Moss AJ. Children’s Exposure to Environmental Cigarette Smoke Before and After Birth: 

Health of Our Nation’s Children, United States, 1988. 

Advance Data. No. 202. Hyattsville (MD): US Department of Health and Human Services, Public Health 

Service, Centers for Disease Control, National Center 

for Health Statistics. DHHS Publication No. (PHS) 91­

1250, 1991. 

Pamuk ER, Mosher WD. Health Aspects of Pregnancy 

and Childbirth: United States, 1982. Vital and Health 

Statistics. Series 23, No. 16. Hyattsville (MD): US Department of Health and Human Services, Public Health 

Service, Centers for Disease Control, National Center 

for Health Statistics. DHHS Publication No. (PHS) 89­

1992, 1992. 

Parnell K, Sargent R, Thompson SH, Duhe SF, Valois 

RF, Kemper RC. Black and white adolescent females’ 

perceptions of ideal body size. Journal of School Health 

1996;66(3):112–8. 

Patterns of Tobacco Use 131 
 

Surgeon General's Report 

Pattishall EN, Strope GL, Etzel RA, Helms RW, Haley 

NJ, Denny FW. Serum cotinine as a measure of tobacco 

smoke exposure in children. American Journal of Diseases of Children 1985;139(11):1101–4. 

Pierce JP, Fiore MC, Novotny TE, Hatziandreu EJ, 

Davis RM. Trends in cigarette smoking in the United 

States: educational differences are increasing. Journal 

of the American Medical Association 1989;261(1):56–60. 

Pierce JP, Gilpin E, Burns DM, Whalen E, Rosbrook B, 

Shopland D, et al. Does tobacco advertising target 

young people to start smoking? evidence from California. Journal of the American Medical Association 1991a; 

266(22):3154–8. 

Pierce JP, Naquin M, Gilpin E, Giovino G, Mills S, 

Marcus S. Smoking initiation in the United States: a 

role for worksite and college smoking bans. Journal of 

the National Cancer Institute 1991b;83(14):1009–13. 

Pirkle JL, Flegal KM, Bernert JT, Brody DJ, Etzel RA, 

Maurer KR. Exposure of the U.S. population to environmental tobacco smoke: the third National Health 

and Nutrition Examination Survey, 1988–1991. Journal of the American Medical Association 1996;275(16): 

1233–40. 

Pletsch PK. Prevalence of cigarette smoking in Hispanic women of childbearing age. Nursing Research 

1991;40(2):103–6. 

Remington PL, Smith MY, Williamson DF, Anda RF, 

Gentry EM, Hogelin GC. Design, characteristics, and 

usefulness of state-based behavioral risk factor surveillance: 1981–87. Public Health Reports 1988;103(4): 

366–75. 

Roscoe RJ, Deddens JA, Salvan A, Schnorr TM. Mortality among Navajo uranium miners. American Journal of Public Health 1995;85(4):535–40. 

Rouse BA. Epidemiology of smokeless tobacco use: a 

national study. In: National Cancer Institute. Smokeless Tobacco Use in the United States. National Cancer 

Institute Monograph No. 8. Bethesda (MD): US Department of Health and Human Services, Public Health 

Service, National Cancer Institute, Division of Cancer 

Prevention and Control, Smoking, Tobacco, and 

Cancer Program. NIH Publication No. 89-3055, 1989: 

29–33. 

Royce JM, Hymowitz N, Corbett K, Hartwell TD, 

Orlandi MA, for the COMMIT Research Group. Smoking cessation factors among African Americans and 

whites. American Journal of Public Health 1993;83(2): 

220–6. 

Samet JM, Howard CA, Coultas DB, Skipper BJ. Acculturation, education, and income as determinants of 

cigarette smoking in New Mexico Hispanics. Cancer 

Epidemiology, Biomarkers & Prevention 1992;1(3): 

235–40. 

Shah BV. SESUDAAN: Standard Errors Program for Computing of Standardized Rates from Sample Survey Data. 

Research Triangle Park (NC): Research Triangle Institute, 1981. 

Shah BV, Barnwell BG, Hunt PN, LaVange LM. 

SUDAAN: Professional Software for Survey Data Analysis (SUDAAN User’s Manual, Release 5.50). Research 

Triangle Park (NC): Research Triangle Institute, 1991. 

Sheridan DP, Hornung CA, McCutcheon EP, Wheeler 

FC. Demographic and educational differences in smoking in a tobacco-growing state. American Journal of Preventive Medicine 1993;9(3):155–9. 

Shopland DR, Hartman AM, Gibson JT, Mueller MD, 

Kessler LG, Lynn WR. Cigarette smoking among U.S. 

adults by state and region: estimates from the Current 

Population Survey. Journal of the National Cancer Institute 1996;88(23):1748–58. 

Smith KW, McGraw SA, Carrillo JE. Factors affecting 

cigarette smoking and intention to smoke among 

Puerto Rican-American high school students. Hispanic 

Journal of Behavioral Sciences 1991;13(4):401–11. 

Sugarman JR, Brenneman G, LaRoque W, Warren CW, 

Goldberg HI. The urban American Indian oversample 

in the 1988 National Maternal and Infant Health Survey. Public Health Reports 1994;109(2):243–50. 

Sugarman JR, Warren CW, Oge L, Helgerson SD. Using the Behavioral Risk Factor Surveillance System to 

monitor year 2000 objectives among American Indians. Public Health Reports 1992;107(4):449–56. 

Thomas RM, Larsen MD. Smoking prevalence, beliefs, 

and activities: by gender and other demographic indicators. Paper presented at the 1993 AAPOR Annual 

Convention, St. Charles, Illinois, May 1993. 

132 Chapter 2 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Thornberry OT Jr, Massey JT. Trends in United States 

telephone coverage across time and subgroups. In: 

Groves RM, Biemer PP, Lyberg LE, Massey JT, Nicholls 

WL II, Waksberg J, editors. Telephone Survey Methodology. New York: John Wiley & Sons, 1988:25–49. 

US Bureau of the Census. Statistical Brief: Phoneless in 

America. Washington (DC): US Department of Commerce, Economics and Statistics Administration, Bureau of the Census. SB/94-16, 1994. 

US Department of Health and Human Services. The 

Health Consequences of Smoking for Women. A Report of 

the Surgeon General. Rockville (MD): US Department 

of Health and Human Services, Public Health Service, 

Office of the Assistant Secretary for Health, Office on 

Smoking and Health, 1980. 

US Department of Health and Human Services. The 

Health Consequences of Smoking: Cardiovascular Disease. 

A Report of the Surgeon General. Rockville (MD): US 

Department of Health and Human Services, Public 

Health Service, Office on Smoking and Health. DHHS 

Publication No. (PHS) 84-50204, 1983. 

US Department of Health and Human Services. The 

Health Consequences of Smoking: Cancer and Chronic Lung 

Disease in the Workplace. A Report of the Surgeon General. 

Rockville (MD): US Department of Health and Human 

Services, Public Health Service, Office on Smoking and 

Health. DHHS Publication No. (PHS) 85-50207, 1985. 

US Department of Health and Human Services. The 

Health Consequences of Smoking: Nicotine Addiction. A 

Report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, Public Health 

Service, Centers for Disease Control, Center for Health 

Promotion and Education, Office on Smoking and 

Health. DHHS Publication No. (CDC) 88-8406, 1988. 

US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of 

Progress. A Report of the Surgeon General. Atlanta: US 

Department of Health and Human Services, Public 

Health Service, Centers for Disease Control, Center for 

Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health. DHHS Publication No. 

(CDC) 89-8411, 1989. 

US Department of Health and Human Services. The 

Health Benefits of Smoking Cessation. A Report of the Surgeon General. Rockville (MD): US Department of Health 

and Human Services, Public Health Service, Centers 

for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and 

Health. DHHS Publication No. (CDC) 90-8416, 1990a. 

US Department of Health and Human Services. Tobacco 

Use in 1986: Methods and Basic Tabulations from Adult 

Use of Tobacco Survey. Rockville (MD): US Department 

of Health and Human Services, Public Health Service, 

Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health. DHHS Publication No. (OM) 90­

2004, 1990b. 

US Department of Health and Human Services. Smoking and Health in the Americas. A 1992 Report of the Surgeon General. Atlanta: US Department of Health and 

Human Services, Centers for Disease Control, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 92-8419, 1992. 

US Department of Health and Human Services. Preventing Tobacco Use Among Young People. A Report of the 

Surgeon General. Atlanta: US Department of Health and 

Human Services, Public Health Service, Centers for 

Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health, 1994. 

US Department of Health, Education, and Welfare. 

Smoking and Health. A Report of the Surgeon General. 

Washington (DC): US Department of Health, Education, and Welfare, Public Health Service, Office of the 

Assistant Secretary for Health, Office on Smoking and 

Health. DHEW Publication No. (PHS) 79-50066, 1979. 

Vega WA, Gil AG, Zimmerman RS. Patterns of drug 

use among Cuban-American, African-American, and 

white non-Hispanic boys. American Journal of Public 

Health 1993;83(2):257–9. 

Ventura SJ, Martin JA, Taffel SM, Mathews TJ, Clarke 

SC. Advance Report of Final Natality Statistics, 1992. 

Monthly Vital Statistics Report 1994;43(5 Suppl). 

Ventura SJ, Martin JA, Taffel SM, Mathews TJ, Clarke 

SC. Advance Report of Final Natality Statistics, 1993. 

Monthly Vital Statistics Report 1995;44(3 Suppl). 

Patterns of Tobacco Use 133 
 

Surgeon General's Report 

Ventura SJ, Martin JA, Mathews TJ, Clarke SC. Advance Report of Final Natality Statistics, 1994. Monthly 

Vital Statistics Report 1996;44(11 Suppl). 

Ventura SJ, Martin JA, Curtin SC, Mathews TJ. Report 

of Final Natality Statistics, 1995. Monthly Vital Statistics Report 1997;45(11 Suppl). 

Wagenknecht LE, Burke GL, Perkins LL, Haley NJ, 

Friedman GD. Misclassification of smoking status in 

the CARDIA study: a comparison of self-report with 

serum cotinine levels. American Journal of Public Health 

1992;82(1):33–6. 

Wagenknecht LE, Manolio TA, Sidney S, Burke GL, 

Haley NJ. Environmental tobacco smoke exposure as 

determined by cotinine in black and white young 

adults: the CARDIA study. Environmental Research 

1993;63(1):39–46. 

Wallace JM Jr, Bachman JG. Explaining racial/ethnic 

differences in adolescent drug use: the impact of background and lifestyle. Social Problems 1991;38(3):333–57. 

Wang S-Q, Yu J-J, Zhu B-P, Liu M, He G-Q. Cigarette 

smoking and its risk factors among senior high school 

students in Beijing, China, 1988. Tobacco Control 

1994;(3):107–14. 

Warm Springs Confederated Tribes. Warm Springs Confederated Tribes Behavioral Risk Factor Survey, 1990. Warm 

Springs (OR): Warm Springs Confederated Tribes, 

Community Health Promotion Department, Human 

Services Branch, 1993. 

Welty TK, Lee ET, Yeh J, Cowan LD, Go O, Fabsitz RR, 

et al. Cardiovascular disease risk factors among American Indians: the Strong Heart Study. American Journal 

of Epidemiology 1995;142(3):269–87. 

Weng X-Z, Hong Z-G, Chen D-Y. Smoking prevalence 

in Chinese aged 15 and above. Chinese Medical Journal 

1987;100(11):886–92. 

Wewers ME, Dhatt RK, Moeschberger ML, Guthrie 

RM, Kuun P, Chen MS. Misclassification of smoking 

status among Southeast Asian adult immigrants. 

American Journal of Respiratory and Critical Care Medicine 1995;152(6 Pt1):1917–21. 

Wiecha JM. Differences in patterns of tobacco use in 

Vietnamese, African-American, Hispanic, and Caucasian adolescents in Worcester, Massachusetts. American Journal of Preventive Medicine 1996;12(1):29–37. 

Wills TA, Cleary SD. The validity of self-reports of 

smoking: analyses by race/ethnicity in a school sample 

of urban adolescents. American Journal of Public Health 

1997;87(1):56–61. 

Zhu B-P, Liu M, Wang S-Q, He G-Q, Chen D-H, Shi 

JH, et al. Cigarette smoking among junior high school 

students in Beijing, China, 1988. International Journal 

of Epidemiology 1992;21(5):854–61. 

134 Chapter 2 
Chapter 3
 

Health Consequences of Tobacco Use
 

Among Four Racial/Ethnic Minority Groups
 

Introduction 137
 

Lung Cancer 137
 

African Americans 138
 

American Indians and Alaska Natives 143
 

Asian Americans and Pacific Islanders 145
 

Hispanics 147
 

Other Cancers 149
 

Cervical Cancer 152
 

Esophageal Cancer 153
 

Oral Cancer 153
 

Stomach Cancer 155
 

Urinary Bladder Cancer 156
 

Chronic Obstructive Pulmonary Disease 158
 

African Americans 158
 

American Indians and Alaska Natives 158
 

Asian Americans and Pacific Islanders 159
 

Hispanics 159
 

Coronary Heart Disease 160
 

African Americans 160
 

American Indians and Alaska Natives 161
 

Asian Americans and Pacific Islanders 162
 

Hispanics 163
 

Cerebrovascular Disease 164
 

African Americans 165
 

American Indians and Alaska Natives 165
 

Asian Americans and Pacific Islanders 165
 

Hispanics 166
 

Smoking and Pregnancy 166
 

Studies of Low Birth Weight 167
 

Studies of Infant Mortality and Sudden Infant Death Syndrome 169
 

Health Problems Affecting Pregnant Women 171
 

Implications 171
 

Summary of Health Consequences from Active Cigarette Smoking 172
 
 

Effects of Exposure to Environmental Tobacco Smoke 172
 

Effects of Smokeless Tobacco Use 174
 

Nicotine Addiction and Racial/Ethnic Differences 175
 

Nature of Addiction 175
 

Pharmacologic Factors in Nicotine Addiction 175
 

Absorption, Distribution, and Elimination of Nicotine in the Body 175
 

Pharmacodynamics of Nicotine 176
 

Tolerance, Withdrawal, and Addictive Tobacco Use 178
 

Level of Addiction 179
 

Racial/Ethnic Differences in Nicotine Metabolites 179
 

Racial/Ethnic Differences in Self-Reported Nicotine Dependence 181
 

Racial/Ethnic Differences in Quitting Smoking 183
 

Addiction to Smokeless Tobacco 183
 

Conclusions 185
 

Appendix. Methodological Issues 185
 

Classification of Smoking Status 185
 

Classification of Race/Ethnicity 186
 

Classification of Health Outcomes 187
 

References 188 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Introduction 

The fact that cigarette smoking causes cancer, 

respiratory and cardiovascular diseases, and adverse 

pregnancy outcomes is well established (U.S. Department of Health and Human Services [USDHHS] 

1989b). Evidence of the relationship between smoking and lung cancer began to accumulate as early as 

the late 1930s (Ochsner and DeBakey 1939; U.S. Department of Health, Education, and Welfare 

[USDHEW] 1964). In 1964, the first Surgeon General’s 

report linking smoking to disease concluded that cigarette smoking was a cause of lung and laryngeal cancers in men and a probable cause of lung cancer in 

women. In more recent reports, the Surgeon General 

has concluded that cigarette smoking causes 87 percent of lung cancer deaths, 30 percent of all cancer 

deaths, 82 percent of chronic obstructive pulmonary 

disease (COPD) deaths, 21 percent of coronary heart 

disease (CHD) deaths, and 18 percent of deaths from 

stroke (USDHHS 1989b) as well as 21–39 percent of 

low-birth-weight births and 14 percent of preterm deliveries (USDHHS 1980, 1989b). In addition, passive 

or involuntary smoking causes lung cancer in healthy 

nonsmokers and respiratory problems in young children (USDHHS 1986a; U.S. Environmental Protection 

Agency 1992). 

Despite this wealth of knowledge about the 

health consequences of smoking, few studies have 

Lung Cancer 

examined the relationship between tobacco use and 

known health effects among racial/ethnic groups in 

the United States. Moreover, few databases include 

information on sufficient numbers of persons from 

racial/ethnic groups to allow such analyses. 

Although sufficient data are often not available 

for these population subgroups, the objectives of this 

chapter are to assess the burden of smoking-related 

diseases among U.S. racial/ethnic groups, to examine 

racial/ethnic differences in tobacco-related morbidity 

and mortality when possible, and to review studies 

that have examined how the relationship between tobacco use and selected health outcomes may differ 

among racial/ethnic groups. For many of the adverse 

health outcomes and diseases presented in this chapter, smoking is one of many contributing factors. The 

focus in this chapter is on the disease burden related 

to smoking among four U.S. racial/ethnic minority 

groups (African Americans, American Indians and 

Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics); data on the contribution of 

cigarette smoking to any differences between groups 

are highlighted whenever available. A discussion of 

some relevant methodological issues is provided in the 

chapter appendix. 

The 1964 Surgeon General’s report on smoking 

and health concluded that “Cigarette smoking is causally related to lung cancer in men; the magnitude of 

the effect far outweighs all other factors. The data for 

women, though less extensive, point in the same direction” (USDHEW 1964). That conclusion was based 

on strong epidemiological evidence from case-control 

and cohort studies and supporting toxicological evidence. When reviewed against criteria for causality, 

the evidence was initially judged to be sufficient for 

men and a similar conclusion was subsequently 

reached for women (USDHHS 1980). 

Since the 1964 Surgeon General’s report, 

voluminous evidence has accumulated about the 

relationship between smoking and lung cancer 

(USDHHS 1989b; Wu-Williams and Samet 1994). The 

epidemiological studies consistently indicate that the 

risk of lung cancer increases with the number of cigarettes smoked and with the length of time a person 

smokes. Furthermore, evidence shows that in comparison with smokers of non-filtered cigarettes, smokers of filtered cigarettes have only slightly less risk of 

lung cancer (Wu-Williams and Samet 1994). Although 

a family history of lung cancer is associated with increased risk, the genetic basis for this association has 

not yet been determined (Economou et al. 1994). Environmental agents other than cigarette smoke, including certain occupational agents (Coultas and Samet 

Health Consequences 137 
 

150 

140 

130 

120 

110 

Rate per 100,000 100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 

Year of Diagnosis 

African American men White men African American women White women 

Surgeon General's Report 

1992; Coultas 1994) and indoor and outdoor air pollutants (Samet 1993), also cause lung cancer. For example, synergism between smoking and radon and 

asbestos has been demonstrated in studies of worker 

groups (Saracci and Boffetta 1994). 

Because nearly all cases of lung cancer are attributable to cigarette smoking, variations in lung cancer 

patterns between racial/ethnic groups most likely reflect differences in smoking patterns. Whenever more 

detailed information is available, it is included in the 

appropriate sections that follow. 

African Americans 

The population-based cancer registries operated 

by the National Cancer Institute’s (NCI) Surveillance, 

Epidemiology, and End Results (SEER) Program provide cancer incidence data for several locations 

throughout the United States, including Connecticut, 

Hawaii, Iowa, New Mexico, and Utah and the metropolitan areas of Detroit, Atlanta, San Francisco/ 

Oakland, and Seattle/Puget Sound. SEER data show 

that African American men have had consistently 

higher lung cancer incidence rates than white men 

since the 1970s (Figure 1) (Kosary et al. 1995). (SEER 

data cover about 10 percent of the U.S. population and 

are used frequently to estimate national cancer rates 

and trends.) Between 1950 and 1960, age-adjusted 

death rates for malignant neoplasms of the respiratory 

system (composed primarily of deaths from lung cancer) among African American men surpassed those 

among white men and have since remained higher, 

whereas death rates for African American women have 

remained fairly similar to those among white women, 

according to data from the National Vital Statistics 

System (Table 1) (National Center for Health Statistics 

[NCHS] 1997). Since 1990, respiratory cancer death 

rates declined substantially for African American men; 

among African American women, rates increased 

through 1990 and then leveled off. From 1992–1994, 

the age-adjusted death rate for cancer of the trachea, 

bronchus, and lung (generally referred to as lung 

Figure 1. Incidence of cancer of the lung and bronchus, by race/ethnicity and gender, National Cancer 

Institute’s Surveillance, Epidemiology, and End Results (SEER) Program, 1973–1994 

Note: Age-adjusted to the 1970 standard U.S. population. 

Sources: Adapted from Kosary et al. 1995; Ries et al. 1997. 

138 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 1.	 Death rates per 100,000 U.S. residents for malignant diseases of the respiratory system, by race/ 

ethnicity and gender, United States, 1950–1995,* selected years 

Race/ethnicity 

and gender 1950† 1960† 1970 1980 1985 1990 1992 1993 1994 1995 

African American men 

All ages, age-adjusted 16.9 36.6 60.8 82.0 87.7 91.0 86.7 86.0 82.8 80.5 

All ages, crude 14.3 31.1 51.2 70.8 75.5 77.8 74.7 74.7 72.5 71.2 

American Indian or 

Alaska Native men‡ 

All ages, age-adjusted NA NA NA 23.2 28.4 29.7 31.7 31.0 31.1 32.7 

All ages, crude NA NA NA 15.7 19.6 21.1 23.1 23.1 23.0 25.1 

Asian American or Pacific 

Islander men§ 

All ages, age-adjusted NA NA NA 27.6 26.9 26.8 27.4 28.4 28.0 25.8 

All ages, crude NA NA NA 22.9 21.3 21.7 23.0 23.8 23.9 22.4 

Hispanic menΔ 

All ages, age-adjusted NA NA NA NA 24.0 27.7 24.4 25.1 24.8 25.2 

All ages, crude NA NA NA NA 13.9 17.4 15.9 16.5 16.5 16.9 

White men 

All ages, age-adjusted 21.6 34.6 49.9 58.0 58.7 59.0 56.7 56.3 54.8 53.7 

All ages, crude 24.1 39.6 58.3 73.4 77.6 81.0 79.5 79.7 78.5 77.8 

African American women 

All ages, age-adjusted 4.1 5.5 10.9 19.5 22.8 27.5 28.5 27.3 27.7 27.8 

All ages, crude 3.4 4.9 10.1 19.3 23.5 29.2 30.9 30.2 30.8 31.3 

American Indian or 

Alaska Native women‡ 

All ages, age-adjusted NA NA NA 8.1 11.1 13.5 15.5 16.1 17.7 16.4 

All ages, crude NA NA NA 6.4 9.2 11.3 13.4 14.6 16.5 15.5 

Asian American or Pacific 

Islander women§ 

All ages, age-adjusted NA NA NA 9.5 9.2 11.3 11.1 11.7 11.2 13.0 

All ages, crude NA NA NA 8.4 8.2 10.6 11.1 11.7 11.4 13.6 

Hispanic womenΔ 

All ages, age-adjusted NA NA NA NA 6.7 8.7 8.4 8.2 8.5 8.2 

All ages, crude NA NA NA NA 5.2 7.5 7.5 7.3 7.7 7.5 

White women 

All ages, age-adjusted 4.6 5.1 10.1 18.2 22.7 26.5 27.4 27.6 27.7 27.9 

All ages, crude 5.4 6.4 13.1 26.5 34.8 43.4 46.2 47.3 47.9 48.9 

Note: Data in the table on African Americans, American Indians and Alaska Natives, Asian Americans and 

Pacific Islanders, and whites include persons of Hispanic and non-Hispanic origin. Conversely, in this table, the 

data on Hispanic origin may include persons of any race. 

*Age-adjusted to the 1940 U.S. standard population. Cause-of-death data are based on classifications from the 

then-current International Classification of Diseases (e.g., cause-of-death codes 160–165 for the Ninth Revision).
 

Data for the 1980s are based on intercensal population estimates.
 

†Includes deaths of nonresidents of the United States. 

‡Interpretation of trends should consider that population estimates for American Indians and Alaska Natives 

increased by 45 percent between 1980 and 1990 (because of better enumeration techniques in 1990 and an 

increased tendency for people to denote themselves as American Indian in 1990). 

§Interpretation of trends should consider that the Asian population in the United States more than doubled 

between 1980 and 1990, primarily because of immigration.

ΔBecause of incomplete data, the National Center for Health Statistics (NCHS) reports 1985 death certificate data 

on decedents of Hispanic origin for only 17 states and the District of Columbia. By 1990, data for 47 states and 

the District of Columbia were reported. NCHS estimates that the 1990 reporting area encompassed 99.6 percent 

of the U.S. Hispanic population. After 1992, only Oklahoma did not provide information on Hispanic origin. 

NA = data not available.
 

Source: Adapted from National Center for Health Statistics 1997.
 

Health Consequences 139 
 

Surgeon General's Report 

cancer) was highest for African American men (81.6 

per 100,000 population) (Table 2); the lung cancer death 

rate for African American women (27.2 per 100,000) 

was similar to that for white women (27.9 per 100,000) 

and higher than that for any other racial/ethnic group. 

Among African Americans in 1993, the four leading 

causes of cancer death were lung cancer (26.1 percent 

of all cancer deaths), cancer of the colon and rectum 

(10.4 percent), prostate cancer (9.4 percent), and cancer of the female breast (8.3 percent) (Parker et al. 1997). 

The higher lung cancer incidence and death rates 

among African American men have not been fully explained. Two ecological analyses of population-based 

incidence data for metropolitan areas have shown that 

the African American-white gradient in lung cancer 

occurrence among men was consistent with gradients 

in socioeconomic indicators (Devesa and Diamond 

1983; Baquet et al. 1991) and that the difference in lung 

cancer disappeared when the data were adjusted for 

socioeconomic status. The authors of one paper 

(Baquet et al. 1991) surmised that the differences in 

smoking patterns associated with socioeconomic status accounted for the differences in lung cancer between white and African American men, whereas the 

authors of the other paper (Devesa and Diamond 1983) 

proposed that cigarette smoking and other environmental correlates of socioeconomic status, such as 

dietary habits or occupational exposure, may have 

accounted for their findings. 

Data from several National Health Interview 

Surveys (NHISs) were used to conduct birth cohort 

analyses of cigarette smoking prevalence in the 1900s 

for African Americans and whites of both genders 

(Tolley et al. 1991; Shopland 1995). Older white men 

(those born before 1915) experienced higher peak 

smoking rates and slightly earlier ages of initiation 

than older African American men. For persons born 

after 1915, peak smoking rates and duration of smoking for African American men were slightly higher than 

those for white men. In addition, white male smokers 

were more likely than African American male smokers to quit smoking in the 1950s (when the early 

scientific studies on smoking and lung cancer were 

reported); African American male cohorts born after 

1915 thus experienced a greater cumulative exposure 

to cigarette smoke. Reflecting these trends in smoking behavior, lung cancer mortality rates were initially 

higher for white men. The combination of less cessation, higher peak prevalence, and longer duration 

of smoking in African American men after the 1940s 

likely explains the observation that mortality rates for 

African American men began to exceed those for white 

men later in the century (Shopland 1995). 

Lung cancer death rates have been much lower 

for women than for men (reflecting historically lower 

smoking prevalences) and have risen more slowly with 

age in the older birth cohorts. As rates for men began 

to decline in cohorts born after 1930, rates continued 

to rise among women, reflecting their slower adoption and increasing prevalence of cigarette smoking. 

African American and white women indicated similar patterns of smoking initiation, maintenance, and 

quitting; lung cancer death rates for African American and white women also have been similar (Tolley 

et al. 1991; Shopland 1995). These data are consistent 

with the interpretation that trends in smoking behavior are largely responsible for 20th century lung cancer mortality patterns for African Americans and 

whites. Tolley and colleagues (1991) further suggested 

that lung cancer rates among African American men 

and women may be slightly higher than those for white 

men and women, even after considering differences 

in their smoking behaviors. 

One study (Harris et al. 1993) showed a higher 

lung cancer risk among African Americans compared 

with whites who had the same level of cumulative 

exposure to cigarette smoking. In this 20-year casecontrol study, 2,678 cases of lung cancer were identified among white men, 238 cases among African 

American men, 1,394 cases among white women, and 

113 among African American women; after adjusting 

the data for cumulative tar consumption and education, the researchers found that African Americans had 

a significantly higher risk of lung cancer. One limitation of this study is that it uses the Federal Trade 

Commission’s (FTC’s) estimates of tar yield to calculate cumulative tar consumption. The FTC’s machines 

are set to parameters that have not changed for decades. Because humans smoke cigarettes differently 

than the machines used by the FTC, the validity of 

these measures has been called into question (NCI 

1996a). In the Kaiser Permanente cohort study, the 

relative risks of lung cancer were approximately the 

same for African Americans and whites (Friedman et 

al. 1997). Dorgan and colleagues (1993) conducted a 

case-control study to assess race and gender differences 

in lung cancer, categorizing participants according to 

consumption of fruits and vegetables. Lung cancer 

risk was significantly increased for African Americans 

who currently smoked (compared with never smokers and former light smokers), regardless of the amount 

of vegetables consumed. These analyses were statistically adjusted for gender, age, education, occupation, 

passive smoking, and study phase. 

In a recent population-based case-control 

study to compare the risks of lung cancer for African 

140 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 2.	 Age-adjusted death rates* for selected smoking-related causes of death, by race/ethnicity and 

gender, United States, 1992–1994 

African American Indian/ Asian American/ 

Disease Category 

American Alaska Native Pacific Islander White Hispanic 

(ICD-9 code)

† Men Women Men Women Men Women Men Women Men Women 

Cancer 

Lip, oral cavity, 

pharynx (140–149) 7.7 1.8 2.6 1.0 3.3 1.0 3.0 1.2 2.4 0.5 

Esophagus (150) 11.4 3.0 3.2 0.5 2.7 0.5 4.4 0.9 2.8 0.4 

Stomach (151) 9.5 4.1 4.9 2.6 8.9 5.1 3.9 1.7 6.2 3.1 

Pancreas (157) 11.1 8.1 3.4 3.0 5.5 3.9 7.3 5.2 5.1 3.8 

Larynx (161) 4.6 0.8 0.9 0.3 0.6 0.1 1.7 0.4 1.3 0.2 

Trachea, bronchus, 

lung (162) 81.6 27.2 33.5 18.4 27.9 11.4 54.9 27.9 23.1 7.7 

Cervix uteri (180) NA 5.7 NA 3.0 NA 2.5 NA 2.2 NA 3.2 

Bladder (188) 3.2 1.6 1.2 0.5 1.5 0.6 3.9 1.1 1.8 0.6 

Kidney, other, unspecified 

urinary organs (189) 4.3 2.0 4.4 2.3 1.8 0.8 4.1 1.9 3.1 1.3 

Cardiovascular diseases 

Coronary heart disease 

(410–414) 138.3 85.0 100.4 45.9 71.7 36.2 132.5 62.9 82.7 43.9 

Cerebrovascular disease 

(430–438) 53.1 40.6 23.9 21.1 29.3 22.4 26.3 22.6 22.7 16.3 

Respiratory diseases 

Bronchitis, emphysema 

(491–492) 4.7 1.6 2.8 1.9 2.9 0.9 6.2 3.8 2.4 0.9 

Chronic airway 

obstruction, not 

elsewhere classified (496) 17.6 6.6 14.2 9.0 7.9 2.6 20.4 12.2 8.2 3.7 

*Per 100,000, age-adjusted to the 1940 U.S. standard population. Estimates for Hispanics exclude data from 

New Hampshire for 1992 and from Oklahoma for 1992–1994. 

†

International Classification of Diseases, Ninth Revision, World Health Organization 1977.
 

NA = data not available.
 

Sources: National Center for Health Statistics, public use data tapes, 1992–1994; U.S. Bureau of the Census 1997.
 

Americans and whites across categories of cigarette 

smoking status, Schwartz and Swanson (1997) examined incident cases from the Occupational Cancer 

Incidence Surveillance Study. This study operates in 

conjunction with the Metropolitan Detroit Cancer 

Surveillance System, a participant in the NCI’s SEER 

Program. The analyses were stratified by gender and 

statistically adjusted for age, education, and cigarette 

smoking behaviors. The overall risks of lung cancer 

(of all histological types) were similar for African 

Health Consequences 141 
 

Surgeon General's Report 

Americans and whites. Thus, race did not appear to 

be an independent predictor of lung cancer in the 

population as a whole. However, African Americans 

were more likely than whites to have developed squamous cell carcinoma. Additionally, African American 

men aged 40–54 years were 2–4 times more likely than 

white men of the same ages to have developed lung 

cancer (of several histological types). The authors concluded that the increased risks among younger 

African Americans may suggest a greater degree of 

susceptibility to lung carcinogens or greater exposure 

to other unidentified carcinogens and they called for 

further research on the topic. 

Investigators have postulated that the more 

frequent smoking of menthol cigarettes by African 

Americans, compared with whites, contributes to their 

increased rate of lung cancer (Harris et al. 1993). In a 

recent experimental study of 12 persons after the 

amount of menthol injected into experimental cigarettes was increased, the amount of carbon monoxide 

exhaled by African American smokers also increased 

(Miller et al. 1994). In a comparison of smoking behavior associated with mentholated cigarettes and 

regular cigarettes among 29 subjects, McCarthy and 

colleagues (1995) found higher mean puff volume and 

higher puff frequency after participants smoked regular cigarettes than after they smoked mentholated 

cigarettes; however, no differences in mean expired 

carbon monoxide levels were found. Available data 

suggest that mentholated cigarettes are not smoked 

more intensely than regular cigarettes (Jarvik et al. 

1994; Miller et al. 1994; McCarthy et al. 1995; Ahijevych 

et al. 1996). Thus, mentholated cigarettes may promote lung permeability and diffusibility of smoke constituents (Jarvik et al. 1994; McCarthy et al. 1995; Clark 

et al. 1996a). 

Recent studies have examined the possible role 

of genetics in determining the risk of lung cancer 

among African Americans. Crofts and colleagues 

(1993) identified a restriction fragment length polymorphism (RFLP) in the gene (CYP1A1) that encodes the 

enzyme responsible for initiating metabolism of 

polyaromatic hydrocarbon compounds found in cigarette smoke (Guengerich 1992, 1993). In one study of 

African Americans, the risk of adenocarcinoma of the 

lung was higher for smokers with the CYP1A1 RFLP 

than for smokers who did not have this RFLP (Taioli 

et al. 1995). Two other studies, however, did not find 

an association between the presence of the variant allele in African Americans and increased lung cancer 

risk (Kelsey et al. 1994; London et al. 1995). Taioli and 

colleagues (1995) also found that persons who had 

adenocarcinoma with the African American CYP1A1 

RFLP had lower lifetime cigarette consumption, as 

measured by pack-years, compared with those who 

had adenocarcinoma without the polymorphism. 

However, using a cutoff point of 35 pack-years, 

London and colleagues (1995) found no association 

between the variant CYP1A1 variant allele and lung 

cancer risk based on smoking history. Additionally, a 

homozygous rare CYP1A1 allele associated with the 

risk of lung cancer among persons from Japan 

(Kawajiri et al. 1990) was found more often in African 

Americans than in whites (Shields et al. 1993). However, in a small case-control study, no association was 

observed between the presence of this polymorphism 

and lung cancer risk (Shields et al. 1993). 

Despite strong research interest in this area, 

scientists have been unable to consistently associate 

variant alleles with lung cancer susceptibility. The frequencies of the polymorphisms of interest appear to 

be low in United States populations studied thus far. 

Low frequencies of the alleles of interest suggest that 

future investigations must allow for an adequate 

sample size of the group under study and adjustment 

for factors such as smoking history and age. In addition, low frequency allelic affects may be negated or 

obscured by high tobacco exposure levels. 

Two phenotypes were identified in African 

American and white persons representing poor and 

extensive extremes of glucuronidation (Richie et al. 

1997). Glucuronidation is considered a detoxification 

pathway because it increases the water solubility of a 

chemical substrate and facilitates excretion (Goldstein 

and Faletto 1993). The ratio of conjugated metabolite 

to free metabolite of a tobacco-specific nitrosamine was 

30 percent higher in the urine of white smokers than 

in African American smokers. This finding suggests 

that African Americans are at higher risk from 

nitrosamine exposure during smoking because 

of a decreased capacity to detoxify carcinogenic 

tobacco-specific nitrosamines. Hence, variability in 

glucuronosyltransferase activity, or in clearance of glucuronide conjugates, may represent another determinant of cancer risk. 

The genetically determined poor, intermediate, 

or enhanced debrisoquine metabolizer phenotype has 

been investigated as a risk factor for lung cancer. 

Homozygous dominant (extensive metabolizer) individuals were found more frequently among white lung 

cancer patients who smoked cigarettes than white 

control patients with COPD who smoked cigarettes 

(Ayesh et al. 1984). Caporaso and colleagues confirmed 

the association between the extensive debrisoquine 

metabolizer phenotype and lung cancer risk. In this 

study, almost equivalent numbers of extensive 

142 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

metabolizers were found among African Americans 

(74 percent) and whites (73 percent) (Caporaso et 

al. 1990). 

Another approach in assessing the possible role 

of genetics is using chromosome breaks to measure 

cancer susceptibility. One research group has developed an in vitro cytogenic assay that measures 

mutagen-induced chromosome breaks in short-term 

lymphocyte cultures. This approach has shown a 

relationship between mutagen sensitivity and elevated 

lung cancer. However, attempts to use this method as 

a predictive marker of racial/ethnic differences in cancer risk in African and Mexican Americans produced 

inconsistent results (Spitz et al. 1995; Strom et al. 1995; 

Wu et al. 1996). 

Carcinogenesis can involve genotoxic mechanisms whereby chemical interactions at critical cellular sites go unrepaired. Alterations in certain genes, 

known as proto-oncogenes and tumor suppressor 

genes, are linked with cancer risk (Land et al. 1983; 

Marshall et al. 1984; Slamon et al. 1984; Klein and Klein 

1985; Denissenko et al. 1996). Some gene alleles that 

are evaluated as markers of lung cancer risk vary in 

their distributions among African Americans and 

whites. For example, in a study of lung cancer cases 

and trauma victim controls, Weston and colleagues 

(1991) found rare Ha-ras-1 alleles more often in the 

lung tissue of African Americans (17 percent) than in 

whites (5 percent). For both groups, the prevalence of 

rare alleles among lung cancer patients was higher than 

among controls (23 percent for African American lung 

cancer cases, 15 percent for African American trauma 

victim controls, 6 percent for white lung cancer cases, 

and 2 percent for white trauma victim controls). These 

findings were confirmed in a second study (Weston 

et al. 1992). African American and white differences 

in distribution of alleles at the L-myc locus and p53 

genotype have also been reported. The authors concluded that L-myc genotypes and p53 variants do not 

predict lung cancer risk (Weston et al. 1992). 

In summary, the higher rates of lung cancer observed among African American men are consistent 

with historical patterns of cigarette smoking in this 

century (Shopland 1995). In addition, African American men aged 40–54 years may be especially susceptible to lung carcinogens (Schwartz and Swanson 1997), 

perhaps because they detoxify them differently (Richie 

et al. 1997). A genetic role in racial and ethnic-specific 

risk for lung cancer cannot be ruled out, because some 

studies have shown that African American populations 

have increased frequencies of rare alleles associated 

with greater risks for developing lung cancer than 

whites. However, because of the low frequency of 

these alleles in the populations under study and the 

possibility of misclassification bias, studies have been 

inconclusive (Shields et al. 1993; Taioli et al. 1995). 

Further, African American smokers prefer mentholated 

cigarettes, and menthol may promote the absorption 

and diffusion of tobacco smoke constituents (Jarvik et 

al. 1994; McCarthy et al. 1995; Clark et al. 1996a). This 

hypothesis has received inconsistent support in the 

epidemiological literature. Kabat and Herbert (1991) 

found no relationship between menthol use and lung 

cancer risk; however, Sidney and colleagues (1995) 

suggested that smoking mentholated cigarettes increased the risk of lung cancer only in male smokers. 

Further research could clarify the nature of individual 

susceptibility and the possible role of mentholation. 

Reduction in cigarette smoking will undoubtedly lead 

to reduction in the risk of lung cancer for African 

Americans. 

American Indians and Alaska Natives 

Since the early 1900s, many studies have documented the low overall occurrence of cancer among 

American Indians compared with whites (Hoffman 

1928; Smith et al. 1956; Smith 1957; Salsbury et al. 1959; 

Sievers and Cohen 1961; Kravetz 1964; Reichenbach 

1967; Creagan and Fraumeni 1972; Dunham et al. 1973; 

Blot et al. 1975; Lanier et al. 1976; Samet et al. 1980, 

1988b; Sorem 1985; Mahoney and Michalek 1991; Nutting et al. 1993). Investigations of lung cancer incidence and deaths have confirmed that lung cancer is 

less frequent among American Indians overall than 

among whites (Coultas et al. 1994). Between 1992 and 

1994, age-adjusted death rates for lung cancer per 

100,000 among American Indian and Alaska Native 

men (33.5) and women (18.4) were slightly higher than 

those among Asian American and Pacific Islanders as 

well as Hispanics, whereas they were lower than rates 

among African Americans and whites (Table 2) (NCHS, 

public use data tapes, 1992–1994; U.S. Bureau of the 

Census 1997). Mortality rates for malignant diseases 

of the respiratory system increased from 1980 through 

1995 among American Indians and Alaska Natives 

(Table 1) (NCHS 1997). 

Nationally, lung cancer is the leading cause of 

cancer death among American Indians and Alaska 

Natives. Among those who died of cancer in 1993, the 

four leading causes of death were lung cancer (26.8 

percent), cancer of the colon and rectum (8.9 percent), 

cancer of the female breast (6.3 percent), and prostate 

cancer (6.0 percent) (Parker et al. 1997). Additionally, 

lung cancer was the leading cause of cancer death 

among both men and women in 10 of the 12 Indian 

Health Consequences 143 
 

80 

All U.S. men 

70 

Alaska 

60 

Rate per 100,000 

North Dakota, 

50 South Dakota, 

and Montana 

40 Michigan, 

Minnesota, and 

30 Wisconsin 

20 Oklahoma 

10 Arizona and 

New Mexico 

0 

1968–1972 1973–1977 1978–1982 1983–1987 

Years 

Surgeon General's Report 

Figure 2. Age-adjusted lung cancer death rates among American Indian and Alaska Native men in 

selected states compared with rates among all U.S. men, 1968–1987* 

*Rates presented here were determined using midpoint population estimates for each 5-year time interval and 

were adjusted to the 1970 U.S. standard population. 

Source: Valway 1992. 

Health Service (IHS) areas (Arizona and New Mexico 

had low rates of lung cancer deaths) (Valway 1992). 

Lung cancer death rates among American Indians and 

Alaska Natives have been rising in most IHS areas (Figures 2 and 3) (Valway 1992); national death rates from 

malignant diseases of the respiratory system have also 

been increasing (Table 1). 

Lung cancer death rates vary by IHS area. Specifically, American Indians in the Southwest have had 

the lowest lung cancer death rates, whereas American 

Indians in Alaska, North Dakota, South Dakota, and 

Montana have had rates nearly as high as those in the 

general U.S. population (Table 3, Figures 2 and 3) 

(Valway 1992). These differences are associated with 

variations in smoking among American Indians and 

Alaska Natives (Centers for Disease Control [CDC] 

1987; Welty et al. 1993). In an analysis of data from the 

1985–1988 Behavioral Risk Factor Surveillance System 

(BRFSS) on 1,055 American Indians, Sugarman and 

colleagues (1992) determined smoking prevalence for 

three groups of states that contained three specific IHS 

areas. In this study, the Plains states (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, 

and Wisconsin) contained the Aberdeen, Bemidji, and 

Billings IHS areas; the West Coast states (California, 

Idaho, and Washington) contained the Portland and 

California IHS areas; and the Southwest states 

(Arizona, New Mexico, and Utah) contained the Albuquerque, Navajo, Tucson, and Phoenix IHS areas. 

Cigarette smoking prevalence rates were highest in the 

Plains states (48.4 percent for men and 57.3 percent 

for women), intermediate in the West Coast states (25.2 

percent for men and 31.6 percent for women), and lowest in the Southwestern states (18.1 percent for men 

and 14.7 percent for women). These general geographic patterns of smoking prevalence paralleled 

patterns of lung cancer mortality (Table 3) (Valway 

1992). The smoking prevalence estimates from the 

1985–1988 BRFSS analyses may be imprecise because 

of relatively small samples. However, other analyses 

(American Indians and Alaska Natives, in Chapter 2; 

Welty et al. 1995) show similar patterns. Another 

144 Chapter 3 
 

Rate per 100,000 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Alaska 

North Dakota, 

South Dakota, 

and Montana 

Michigan, 

Minnesota, and 

Wisconsin 

All U.S. women 

Oklahoma 

Arizona and 

New Mexico 

1968–1972 1973–1977 1978–1982 1983–1987
 

Years
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Figure 3. Age-adjusted lung cancer death rates among American Indian and Alaska Native women in 

selected states compared with rates among all U.S. women, 1968–1987* 

*Rates presented here were determined using midpoint population estimates for each 5-year time interval and 

were adjusted to the 1970 U.S. standard population. 

Source: Valway 1992. 

potential limitation is that American Indians living in 

the California and Portland IHS areas may be more 

likely than American Indians from other IHS areas to 

be misclassified on death certificates as being of other 

racial/ethnic categories (Valway 1992), suggesting that 

death rates for American Indians may be underestimated in these areas (Sorlie et al. 1992). 

Lanier and colleagues (1996) recently reported on 

lung cancer incidence rates for Alaska Native men and 

women. Lung cancer incidence was higher for Alaska 

Natives than it was for the general U.S. population. 

In addition, lung cancer was the most common incident cancer among men and the third most common 

incident cancer among women (after breast cancer and 

cancer of the colon/rectum). Lung cancer incidence 

increased substantially among Alaska Native men 

(by 93 percent) and women (by 241 percent) between 

1969–1973 and 1989–1993. The authors concluded, 

“Reduction in tobacco use would result in the greatest 

decreases in cancer rates in this population” (p. 751). 

Asian Americans and Pacific Islanders 

Two issues should always be kept in mind when 

interpreting data about the health consequences of 

cigarette smoking among Asian Americans and Pacific 

Islanders: the diversity of this group and the paucity 

of data. The Asian American and Pacific Islander 

population of the United States includes approximately 32 national and racial/ethnic groups and nearly 

500 languages and dialects. Although many of these 

persons were born in the United States, many others 

are recent immigrants (see Chapters 1 and 2); yet the 

national data do not indicate these distinctions. Environmental exposures experienced in Asia, such as 

women’s exposure to smoke from cooking fuels, may 

influence lung cancer occurrence among recent immigrants (Coultas et al. 1994). 

From 1980 through 1995, age-adjusted death rate 

for malignant neoplasms of the respiratory system 

(primarily deaths from lung cancer) among Asian 

Health Consequences 145 
 

Surgeon General's Report 

Table 3.	 Death rates for lung cancer among 

American Indians and Alaska Natives, 

by Indian Health Service (IHS) area, 

1984–1988 

Men Women ____________ ____________ 

Areas N Rate* N Rate* 

U.S., all ethnicities 74.2 27.3 

Nine IHS areas*† 307 38.5‡ 203 27.2 

All 12 IHS areas 562 40.1‡ 296 21.4‡ 

Aberdeen 63 68.7 41 45.0‡ 

Alaska 80 75.5 62 68.5‡ 

Albuquerque 12 18.8‡ 5 7.8‡ 

Bemidji 41 63.4‡ 24 40.7‡ 

Billings 36 65.3 33 65.7‡ 

California† 33 33.2‡ 8 6.6‡ 

Nashville 24 41.8‡ 15 25.1 

Navajo 25 11.4‡ 7 4.0‡ 

Oklahoma† 167 46.0‡ 55 14.0‡ 

Phoenix 20 17.2‡ 13 11.5‡ 

Portland† 55 40.5‡ 30 23.4 

Tucson 6 25.9‡ 3 13.5‡ 

*Per 100,000, age-adjusted to the 1970 U.S. standard 

population. Rates based on a small number of 

deaths should be interpreted with caution. 

†

The California, Oklahoma, and Portland IHS areas 

appear to have a problem with underreporting 

Indian ethnicity on death certificates; therefore, a 

separate total is presented for the nine other IHS 

areas, excluding these three areas. 

‡

Denotes a rate significantly different from the rate 

for the overall U.S. population. 

Source: Valway 1992. 

American and Pacific Islander men remained fairly 

constant; this death rate for Asian American and Pacific Islander women increased slightly between 1980 

and 1995 but was substantially lower than for men 

(Table 1) (NCHS 1997). Trends should be interpreted 

with caution because the large numbers of immigrants 

from Asia and the Pacific Islands that came to the 

United States during that time may have influenced 

both disease prevalence in and the age structure of this 

group. During 1992–1994, the age-adjusted death rate 

for lung cancer was 27.9 per 100,000 for Asian American and Pacific Islander men and 11.4 per 100,000 for 

women (Table 2). These rates were slightly higher than 

those for Hispanics and slightly lower than those for 

American Indians and Alaska Natives. In 1993, the 

four leading causes of cancer death among Asian 

Americans and Pacific Islanders were lung cancer (22.3 

percent of all cancer deaths), cancer of the colon and 

rectum (10.4 percent), cancer of the liver and intrahepatic bile duct (8.6 percent), and stomach cancer (7.7 

percent) (Parker et al. 1997). 

Data on lung cancer for more specific subgroups 

have been published in several reports (Baquet et al. 

1986; Ross et al. 1991; Zane et al. 1994; NCI 1996b). 

The most recent data are from NCI’s SEER program 

and provide information for 1988–1992. This report 

includes incidence data from the nine areas included 

in the annual SEER reports (e.g., Kosary et al. 1995) 

and from Los Angeles, San Jose/Monterey, and the 

Alaska Area Native Health Service. Data on Hispanics are predominantly from Los Angeles, New Mexico, 

San Francisco, and San Jose/Monterey. Most Hispanics represented in SEER are Mexican Americans. Data 

on Asian Americans and Pacific Islanders are mainly 

from Los Angeles, Hawaii, San Francisco/Oakland, 

San Jose/Monterey, and Seattle/Puget Sound. Data 

on American Indians are from New Mexico; data from 

the Alaska Native Area Health Service provide information on Alaska Natives (NCI 1996b). 

During 1988–1992, the age-adjusted (to the 1970 

U.S. standard population) incidence per 100,000 population of lung cancer for men was 89.0 for Hawaiians, 

70.9 for Vietnamese, 53.2 for Koreans, 52.6 for Filipinos, 52.1 for Chinese, and 43.0 for Japanese. For comparison purposes, the lung cancer incidence rates were 

117.0 for African American men, 76.0 for white men, 

and 41.8 for Hispanic men. For women, the lung cancer incidence rates were 43.1 for Hawaiians, 31.2 for 

Vietnamese, 25.3 for Chinese, 17.5 for Filipinos, 16.0 

for Koreans, and 15.2 for Japanese. In comparison, the 

lung cancer incidence rates were 44.2 for African 

American women, 41.5 for white women, and 19.5 for 

Hispanic women. 

Age-adjusted lung cancer death rates during 

1988–1992 were, per 100,000 men, 88.9 for Hawaiians, 

40.1 for Chinese, 32.4 for Japanese, and 29.8 for Filipinos; mortality estimates were not available for Koreans and Vietnamese of either gender. In comparison, 

the lung cancer death rates were 105.6 for African 

American men, 72.6 for white men, and 32.4 for Hispanic men. For women, the lung cancer death rates 

were 44.1 for Hawaiians, 18.5 for Chinese, 12.9 for Japanese, and 10.0 for Filipinos. In comparison, the lung 

cancer death rates were 31.9 for white women, 31.5 

for African American women, and 10.8 for Hispanic 

women (NCI 1996b). The lung cancer rates reflect gender differences in smoking rates among Asian American and Pacific Islander populations, as indicated by 

1978–1995 data from the NHISs (see Chapter 2). 

146 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Several studies have identified high rates of lung 

cancer among Native Hawaiians. Data on lung cancer 

among Pacific Islanders from the Hawaii Tumor Registry indicate that Native Hawaiians have the highest 

lung cancer incidence rates among the islands’ other 

racial/ethnic groups, including Japanese, Filipinos, and 

Chinese (Kolonel 1980; Hinds et al. 1981). Using medical records of lung cancer patients and data from a 

population-based survey, Hinds and colleagues (1981) 

assessed the risk of developing lung cancer associated 

with smoking among women in Hawaii. The risk for 

developing lung cancer among women who had ever 

smoked compared with those who had never smoked 

was substantially greater among Native Hawaiian 

women (tenfold higher) than among Japanese women 

(fivefold higher) and Chinese women (twofold higher). 

In a comparison of the risks of smoking among Native 

Hawaiians, Filipinos, Japanese, and Chinese in Hawaii, 

Le Marchand and colleagues (1992) found that Native 

Hawaiian men had the highest risk and that white and 

Filipino women had higher risks than Native Hawaiian women. The pattern of variation of smoking’s 

effect on lung cancer was statistically significant for 

men. These differences persisted after variables for 

beta-carotene and cholesterol intake were included in 

the statistical model. The observation that the risk of 

lung cancer related to smoking may vary among subgroups requires further elucidation. In a cohort study 

of 7,961 Japanese American men who were living in 

Hawaii, the incidence of lung cancer was 11.4 times 

higher in current smokers than in persons who had 

never smoked; the risk for former smokers was 3.1 times 

higher than for never smokers (Chyou et al. 1993). 

Hispanics 

According to NCHS data from 1985 through 1995, 

the age-adjusted death rate for malignant neoplasms 

of the respiratory system (primarily deaths from lung 

cancer) among Hispanic men was about three times 

higher than that for Hispanic women (Table 1) (NCHS 

1997). Trends should be interpreted with caution, because only 17 states and the District of Columbia contributed death certificate data on Hispanics for 1985; 

by 1990, however, 47 states and the District of Columbia, covering 99.6 percent of the U.S. Hispanic population, contributed relevant data (Table 1) (NCHS 1997). 

From 1992 through 1994, the age-adjusted death rate 

for cancer of the trachea, bronchus, and lung (generally referred to as lung cancer) was 23.1 per 100,000 

for Hispanic men and 7.7 per 100,000 for Hispanic 

women (Table 2). Overall, lung cancer is the leading 

cause of cancer death among Hispanics. Among those 

who died of cancer in 1993, the four leading causes of 

death were lung cancer (17.9 percent), cancer of the 

colon and rectum (9.6 percent), cancer of the female 

breast (8.2 percent), and cancer of the liver and other 

biliary organs (6.0 percent) (Parker et al. 1997). Among 

Hispanic women, however, breast cancer mortality 

exceeds that of lung cancer (NCI 1996b). 

National mortality data for 1992–1994 (Table 4) 

also indicate that rates of lung cancer per 100,000 

were higher among Cuban men (33.7) than among 

Mexican American (28.3) and Puerto Rican men (21.9). 

Among women, little variation is evident across Hispanic subgroups (Table 4). An earlier nationwide 

analysis limited to foreign-born Cubans, Mexicans, and 

Puerto Ricans provided similar results for 1979–1981 

(Rosenwaike 1987). 

Some regional data suggest that rates of lung 

cancer among Hispanics increased rapidly. For example, New Mexico mortality data for 1958–1982 

indicate that lung cancer death rates increased for successive birth cohorts of Hispanics (Samet et al. 1988b). 

Between 1958–1962 and 1978–1982, lung cancer death 

rates per 100,000 increased from 10.1 to 28.8 among 

Hispanic men and from 4.8 to 11.2 among 

Hispanic women (Samet et al. 1988b). However, lung 

cancer death rates among Hispanics remained below 

those of the general U.S. population. Moreover, between 1969–1971 and 1979–1981, lung cancer incidence 

rates doubled for persons with Spanish surnames (not 

necessarily all persons were Hispanic) residing in the 

Denver, Colorado, area (Savitz 1986). 

National and regional vital statistics have shown 

that patterns of lung cancer incidence differ among 

Hispanics and whites throughout the United States 

(NCHS 1994). Much of the information available on 

lung cancer incidence has relied on the SEER Program, 

which for many years included only one subgroup of 

Hispanics—those residing in New Mexico. 

Since the 1950s, descriptive studies of death have 

documented differing patterns of lung cancer among 

Hispanics and whites in the western and southwestern 

United States. In California, during the 1950s and 1960s, 

age-specific death rates from lung cancer among older 

Mexican-born women were two to three times the rates 

among California women of all ages (Buechley et al. 

1957; Buell et al. 1968). Lung cancer death rates for 

women in Texas and New Mexico during the 1960s and 

1970s showed a similar pattern of age-specific rates (Lee 

et al. 1976; Samet et al. 1980, 1988b), although Hispanic 

women in the West and Southwest have had lower overall lung cancer death rates than white women (Savitz 

1986; Martin and Suarez 1987; Samet et al. 1988b; 

Bernstein and Ross 1991). 

Health Consequences 147 
 

Surgeon General's Report 

Table 4.	 Age-adjusted death rates* for selected smoking-related causes of death among Mexican 

Americans, Puerto Rican Americans, and Cuban Americans, United States, 1992–1994 

Disease category 

(ICD-9 code)† Men Women Men Women Men Women 

Cancer 

Lip, oral cavity, pharynx (140–149) 2.0 0.4 5.5 0.9 3.3 0.7 

Esophagus (150) 2.7 0.3 6.1 1.1 2.7 0.4 

Stomach (151) 6.8 3.5 7.7 3.9 3.1 1.3 

Pancreas (157) 5.4 4.3 5.0 3.6 5.0 4.1 

Larynx (161) 1.1 0.1 2.6 0.3 2.2 0.1 

Trachea, bronchus, lung (162) 21.9 8.0 28.3 9.6 33.7 8.9 

Cervix uteri (180) NA 3.7 NA 3.7 NA 1.6 

Bladder (188) 1.4 0.5 2.1 1.0 3.5 0.5 

Kidney, other, unspecified 

urinary organs (189) 3.7 1.6 1.9 1.0 2.7 1.0 

Cardiovascular diseases 

Coronary heart disease (410–414) 82.3 44.2 118.6 67.3 95.2 42.4 

Cerebrovascular disease (430–438) 25.5 18.9 27.3 16.5 17.1 11.5 

Respiratory diseases 

Bronchitis, emphysema (491–492) 2.2 0.9 3.2 1.3 3.3 1.0 

Chronic airway obstruction, 

not elsewhere classified (496) 7.6 3.7 10.5 5.3 9.1 3.1 

Mexican Puerto Rican Cuban 

*Per 100,000, age-adjusted to the 1940 U.S. standard population. Death rates are not available from New 

Hampshire for 1992 and from Oklahoma for 1992–1994. Due to limitations in the data, the population 

estimates for Oklahoma and New Hampshire were not subtracted from the denominator. Based on the 

1990 Census, the number of persons of Hispanic origin from New Hampshire and Oklahoma represented 

about 0.04 percent of the U.S. Hispanic population. 

†

International Classification of Diseases, Ninth Revision, World Health Organization 1977.
 

NA = data not available.
 

Sources: National Center for Health Statistics, public use data tapes, 1992–1994; U.S. Bureau of the Census 1997.
 

In 1982 and 1983, lung cancer rates among 

Hispanic men and women in Florida also were lower 

than the rates among whites (Trapido et al. 1990a,b). 

More recent data (1981–1989) from Dade County, 

Florida, again show the incidence of lung cancer to be 

lower among Hispanic men than among white men 

and lower among Hispanic women than white women 

(Trapido et al. 1994a,b). Similarly, Mexican and Puerto 

Rican immigrants in Illinois have had lower standardized lung cancer death rates than whites (Mallin and 

Anderson 1988). In addition, lung cancer incidence 

and death rates have been much lower among 

Hispanic men than among white men in New Mexico (Samet et al. 1980), Texas (Lee et al. 1976), California (Menck et al. 1975; Bernstein and Ross 1991), 

Connecticut (Polednak 1993), and Colorado (Savitz 

1986). Mortality data indicate that Puerto Ricans 

living on Long Island, New York, had slightly 

lower death rates for lung cancer than Puerto Ricans 

living elsewhere in the United States (except Puerto 

Rico) (Polednak 1991). However, Puerto Rican men 

and women residing on Long Island had lung cancer 

death rates that were three to four times the rates 

among Puerto Rico residents. 

148 Chapter 3 
 

These lower rates of lung cancer among Hispanics appear to reflect differences in smoking between 

Hispanics and whites. The results of a 1980–1982 

case-control study of lung cancer cases among Hispanics and whites residing in New Mexico indicate that 

the risks (adjusted for gender and age) across categories of smoking consumption among both groups were 

comparable (Table 5) (Humble et al. 1985). This finding suggests that the reduced rates of lung cancer 

deaths among Hispanics are attributable to their lower 

cigarette consumption (number of cigarettes smoked 

daily) and not to some other correlate of Hispanic race/ 

ethnicity. In a mortality study conducted in Texas between 1970 and 1979 using age-standardized death 

rates, Holck and colleagues (1982) found that Mexican American women had stable lung cancer death 

rates (approximately 30 per 100,000), whereas white 

women had increasing rates of death from lung 

cancer. The lower lung cancer rates for Mexican 

American women were consistent with their lower 

prevalence of smoking (18.5 percent of Mexican American women vs. 31.6 percent of white women). 

The elevated rates of lung cancer death among 

older Hispanic women in the West and Southwest have 

been attributed to a possible pattern of early initiation 

of smoking among women born in Mexico before 1900 

as well as the custom of cooking indoors with an open 

fire (Buell et al. 1968; Lee et al. 1976). The findings of a 

1980–1982 case-control study in New Mexico indicate 

that older Hispanic women smoked hand-rolled cigarettes, which may have contributed to the high lung 

cancer death rate among older Mexican American 

women (Humble et al. 1985). 

Other Cancers 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 5.	 Odds ratios for the risk of lung cancer, 

by gender, race/ethnicity, and smoking 

status, case-control study, New Mexico,* 

1980–1982 

Men ________________________ 

Smoking status Hispanic White 

Former smokers 8.0† 7.2 

(1.9–42.2)‡ (3.0–17.6) 

Current smokers 11.6 9.2 

< 20 cigarettes per day (2.7–61.5) (3.3–25.8) 

≥20 cigarettes per day 26.1 24.7 

(5.6–146.6) (10.0–59.9) 

Women ________________________ 

Hispanic White 

Former smokers 6.3† 6.5 

(1.5–27.8) (2.8–15.4) 

Current smokers 18.5 19.2 

< 20 cigarettes per day (4.9–72.4) (6.5–60.8) 

≥20 cigarettes per day 36.9 16.0 

(7.6–217.1) (6.7–36.3) 

*Mantel-Haenszel estimates of exposure odds ratios 

were calculated for two age strata: <65 years of age 

and ≥65 years of age. Odds ratios are relative to 

persons who never smoked.

†p <0.01.

‡

95% Cornfield confidence limits; unless otherwise 

indicated, p <0.0001. 

Source: Adapted from Humble et al. 1985. 

Cigarette smoking causes cancers of the lung, 

larynx, mouth, esophagus, and bladder; is a contributing factor for cancers of the pancreas, kidney, and 

cervix; and is associated with cancer of the stomach 

(USDHHS 1989b, 1990). Cigarette smoking is also suspected of contributing to colon cancer (Giovanucci et 

al. 1994), liver cancer (Doll et al. 1994), and acute 

myeloid leukemia (Siegel 1993). Little information is 

available on cigarette smoking as a risk factor for these 

cancers among members of racial/ethnic minority 

groups. In the annual Cancer Statistics Review of the 

SEER Program, cancer incidence and death rates are 

reported for African Americans and whites (Kosary et 

al. 1995). A special 1986 report provides more detailed 

information on African Americans and other ethnic 

groups for 1978–1981 (Baquet et al. 1986). A more recent report provides detailed information on several 

ethnic groups for 1988–1992 (NCI 1996b). Other 

population-based cancer registries are also beginning 

to contribute relevant information. 

Several recently published sources of information 

on cancer among American Indians include an IHS 

Health Consequences 149 
150 Chapter 3 

Surgeon General's Report 

report, which describes regional differences in cancer populations; and an NCI monograph that documents 

deaths among American Indians in the United States the status of the evidence on cancer and the need for 

for 1984–1988 and time trends for 1968–1987 (Valway additional research regarding cancer among American 

1992); two reports from the Alaska Area Native Health Indians and Alaska Natives (Burhansstipanov and 

Service (Lanier et al. 1993, 1996), which describe can- Dresser 1993). 

cer incidence in the state’s Eskimo, Aleut, and Indian 

Table 6.	 Age-adjusted incidence and death rates* for selected smoking-related cancers, by race/ethnicity and 

gender, National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program, 

1988–1992 

American 

Primary cancer site African Alaska Indian 

(ICD-9 code)† American Native (New Mexico) Chinese Filipino 

All sites 

Incidence rate,§ men 560Δ 372 196 282 274 

Incidence rate, women 326 348 180 213 224 

Death rate,¶ men 319 225 123 139 105 

Death rate, women 168 179 99 86 63 

Cervix uteri (180) 

Incidence rate, women 13.2 15.8 9.9 7.3 9.6 

Death rate, women 6.7 –** – 2.6 2.4 

Esophagus (150) 

Incidence rate, men 15.0 – – 5.3 2.9 

Incidence rate, women 4.4 – – – – 

Death rate, men 14.8 – – 4.2 2.2 

Death rate, women 3.7 – – – – 

Kidney and renal pelvis 

(189.0–189.1) 

Incidence rate, men 12.8 – 15.6 4.6 5.8 

Incidence rate, women 6.0 – – 2.3 2.8 

Death rate, men 5.1 – – 1.3 1.9 

Death rate, women 2.2 – – 0.9 – 

Larynx (161) 

Incidence rate, men 12.7 – – 2.8 2.4 

Incidence rate, women 2.5 – – – – 

Death rate, men 5.6 – – 0.9 – 

Death rate, women 0.9 – – – – 

Lung and bronchus

 (162.2–162.9) 

Incidence rate, men 117.0 81.1 14.4 52.1 52.6 

Incidence rate, women 44.2 50.6 – 25.3 17.5 

Death rate, men 105.6 69.4 – 40.1 29.8 

Death rate, women 31.5 45.3 – 18.5 10.0 

*Rates per 100,000, age-adjusted to the 1970 U.S. standard population. 

†

U.S. Department of Health and Human Services 1989a. 

‡

Includes persons of other ethnic groups who designated themselves as of Hispanic origin. 

§

All incidence data are from five states: Connecticut, Hawaii, Iowa, New Mexico, and Utah; from six 

metropolitan areas: Atlanta (including 10 rural counties), Detroit, Los Angeles, San Francisco/Oakland, 

San Jose/Monterey, and Seattle/Puget Sound; and from the Alaska Area Native Health Service. 
Health Consequences 151 

Death and incidence data both indicate marked 

heterogeneity of cancer occurrence among racial/ 

ethnic groups in the United States, and this heterogeneity extends to the cancer sites associated with cigarette smoking. For example, SEER data indicate that 

African Americans have higher incidence and death rates 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

than whites for a number of smoking-related cancer sites, 

including the oral cavity and pharynx, esophagus, cervix uteri, larynx, stomach, pancreas, and lung (Table 6; 

Figure 4) (Kosary et al. 1995; NCI 1996b). When the ratios of African American to white incidence and death 

rates exceed 1.0 in Figure 4, then African Americans 

Hawaiian Japanese Korean Vietnamese White Hispanic‡ 

340 322 266 326 469 319 

321 241 180 273 346 243 

239 133 NA NA 213 129 

168 88 NA NA 140 85 

9.3 5.8 15.2 43.0 8.7 16.2 

– 1.5 NA NA 2.5 3.4 

9.4 5.6 – – 5.4 4.4 

– – – – 1.7 0.9 

– 4.8 NA NA 5.3 3.4 

– 0.9 NA NA 1.2 0.7 

9.8 7.3 6.3 – 11.9 10.0 

– 2.3 – – 5.9 5.5 

– 2.4 NA NA 5.0 3.7 

– 0.8 NA NA 2.3 1.7 

– 2.5 – – 7.5 5.1 

– – – – 1.5 0.7 

– – NA NA 2.3 1.9 

– – NA NA 0.5 0.2 

89.0 43.0 53.2 70.9 76.0 41.8 

43.1 15.2 16.0 31.2 41.5 19.5 

88.9 32.4 NA NA 72.6 32.4 

44.1 12.9 NA NA 31.9 10.8 

Δ

Estimates for all cancer sites are rounded to the nearest integer. 

¶National Center for Health Statistics, public use data tapes, 1988–1992, is the source for all death rates 

in this table. Death rates are U.S. mortality rates. 

**A dash means that the rate was not calculated for fewer than 25 cases. 

NA = data not available. 

Source: National Cancer Institute 1996b; National Center for Health Statistics, public use data tapes, 1988–1992. 
 

Surgeon General's Report 

Table 6. Continued 

American 

Primary cancer site African Alaska Indian 

(ICD-9 code)† American Native (New Mexico) Chinese Filipino 

Oral cavity excluding 

nasopharynx 

(140.0–146.9; 148.0–149.9) 

Incidence rate,§ men 20.4Δ –** – 5.3 5.4 

Incidence rate, women 5.8 – – 2.3 5.3 

Death rate, men 8.7 – – 1.6 1.2 

Death rate, women 2.1 – – 0.7 1.3 

Pancreas (157) 

Incidence rate, men 14.0 – – 8.0 6.5 

Incidence rate, women 11.5 – – 4.9 6.0 

Death rate,Δ men 14.4 – – 6.7 4.5 

Death rate, women 10.4 – – 5.1 3.5 

Stomach (151) 

Incidence rate, men 17.9 27.2 – 15.7 8.5 

Incidence rate, women 7.6 – – 8.3 5.3 

Death rate, men 13.6 – – 10.5 3.6 

Death rate, women 5.6 – – 4.8 2.5 

Urinary bladder (188) 

Incidence rate, men 15.2 – – 13.0 8.3 

Incidence rate, women 5.8 – – 3.7 2.1 

Death rate, men 4.8 – – 2.0 1.2 

Death rate, women 2.4 – – 1.0 – 

*Rates per 100,000, age-adjusted to the 1970 U.S. standard population. 

†

U.S. Department of Health and Human Services 1989a. 

‡

Includes persons of other ethnic groups who designated themselves as of Hispanic origin. 

§

All incidence data are from five states: Connecticut, Hawaii, Iowa, New Mexico, and Utah; from six 

metropolitan areas: Atlanta (including 10 rural counties), Detroit, Los Angeles, San Francisco/Oakland, 

San Jose/Monterey, and Seattle/Puget Sound; and from the Alaska Area Native Health Service. 

experience excess morbidity and mortality from the cancers shown. Also, SEER data for 1988–1992 show that 

whites have higher rates of some cancers than Hispanics, Asian Americans, Pacific Islanders, American Indians, and Alaska Natives (Table 6) (NCI 1996b). U.S. 

mortality data for 1984–1988 show that American Indians have a lower mortality rate from lung cancer than 

the general U.S. population but a higher mortality rate 

from cervical cancer (Table 7) (Valway 1992). 

Cervical Cancer 

In a case-control Los Angeles County study of 

invasive cervical cancer that included 98 Englishspeaking case-control pairs and 102 Spanish-speaking 

pairs, Peters and colleagues (1986) found that the overall risk of such cancer was increased by cigarette smoking. The cervical cancer risk related to smoking was 

comparable in the two groups. In a more recent study 

of the risk factors for cervical dysplasia among 

Hispanic and white women in New Mexico (Becker et 

al. 1994a,b), cigarette smoking was significantly associated with high-grade cervical dysplasia among white 

women but not among Hispanic women; however, this 

difference in risk was not statistically significant. In 

addition, in a recent pilot study of American Indian 

women in the Albuquerque IHS area, Becker and 

colleagues (1993) found that cigarette smoking was 

associated with cervical dysplasia; however, the results 

were not statistically significant. 

152 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Hawaiian Japanese Korean Vietnamese White Hispanic‡ 

11.7 7.0 – 11.6 14.6 8.9 

– 3.3 – – 5.8 2.7 

– 2.1 NA NA 3.8 2.7 

– 0.8 NA NA 1.5 0.7 

10.9 8.7 – – 9.8 8.0 

8.7 7.3 7.6 – 7.4 6.9 

12.8 8.5 NA NA 9.7 7.1 

9.1 6.7 NA NA 6.9 5.2 

20.5 30.5 48.9 25.8 10.2 15.3 

13.0 15.3 19.1 25.8 4.4 8.0 

14.4 17.4 NA NA 6.1 8.4 

12.8 9.3 NA NA 2.8 4.2 

– 13.7 10.4 – 31.7 15.8 

– 4.1 – – 7.8 4.3 

– 2.0 NA NA 5.8 2.8 

– 1.2 NA NA 1.7 0.9 

ΔEstimates for all cancer sites are rounded to the nearest integer. 

¶

National Center for Health Statistics, public use data tapes, 1988–1992, is the source for all death rates 

in this table. Death rates are U.S. mortality rates. 

**A dash means that the rate was not calculated for fewer than 25 cases. 

NA = data not available. 

Source: National Cancer Institute 1996b; National Center for Health Statistics, public use data tapes, 1988–1992. 

Esophageal Cancer 

Esophageal cancer incidence and death rates in 

the United States are highest among African Americans (Tables 2 and 6) (NCI 1996b). To assess potential 

causes of the high rates of death from esophageal cancer found among African American men, Pottern and 

colleagues (1981) conducted a case-control study in 

Washington, D.C. After adjusting the data for alcohol 

consumption, they found that the relative risk of 

esophageal cancer among smokers was only marginally higher than among nonsmokers. In a more recent 

study, the risk for African American men of developing squamous cell carcinoma of the esophagus was 

significantly elevated for smokers, even after adjusting statistically for age, geographic area, alcohol 

consumption, and income (Brown et al. 1994). 

Smoking mentholated cigarettes may also be a 

cause of the high and rising esophageal cancer rates 

among African Americans. In a case-control study of 

data from the American Health Foundation’s ongoing 

tobacco study, Hebert and Kabat (1989) failed to show 

a consistent effect of smoking mentholated cigarettes 

on the risk of esophageal cancer among African Americans. Better designed studies are needed to adequately 

address this hypothesis. 

Oral Cancer 

Tobacco use and alcohol use are the predominant 

risk factors for cancers of the oral cavity and pharynx 

(commonly referred to as oral cancer) (USDHHS 

1989b). African Americans have the highest oral 

Health Consequences 153 
 

Esophagus

Cervix uteri

Larynx

Prostate gland

Multiple myeloma

Stomach

Oral cavity and pharynx

Corpus and uterus, NOS†

Liver and intrahepatic

Pancreas

Lung (males)

All sites

Thyroid

Colon/rectum

Breast (females)

Urinary bladder

Lung (females)

Kidney and renal pelvis

Leukemia

Hodgkin's

Ovary

Non-Hodgkin’s

Brain and other nervous system

Testis

Melanoma of the skin 

3.5 

3.0 

2.5 

Death rate Incidence 2.0 

1.5 

1.0 

0.5 

0.0 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

0.5 

0.0 

Cancer Site 

Surgeon General's Report 

Figure 4. SEER* cancer incidence and U.S. death rates, 1988–1992, ratio of African American rate to white 

rate for all ages, by cancer site 

*National Cancer Institute’s Surveillance, Epidemiology, and End Results Program; rates are age-adjusted to 

the 1970 U.S. standard population. 

†Not otherwise specified.
 

Source: Kosary et al. 1995.
 

cancer incidence and death rates in the United States 

(Tables 2 and 6) (NCI 1996b). Using underlying causeof-death data compiled by NCHS and U.S. census 

population enumerations and intercensal population 

estimates, investigators found that from 1950 to 1990, 

the death rate for cancers of the oral cavity and pharynx (age-adjusted to the 1970 age distribution of the 

U.S. population) decreased for white men from 6.6 to 

4.2 per 100,000 population. However, for African 

American men, the death rate increased from 4.8 in 

1950 to 11.0 in 1980 and subsequently decreased 

slightly, to 9.8 in 1990. From 1980 through 1990, the 

rate for African American men was approximately 

twice as high as that for white men. The death rate for 

cancers of the oral cavity and pharynx for African 

American women exceeded the rate for white women 

for nearly all of the 41-year period. The death rate 

increased slightly for white women, from 1.5 to 1.6, 

154 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 7.	 Age-adjusted cancer death rates among American Indians and Alaska Natives at all 12 Indian 

Health Service areas, United States, 1984–1988 

Primary cancer site 

Men _____________________________ 

All 12 areas __________________ 

N Rate U.S. rate* 

Women ____________________________ 

All 12 areas __________________ 

N Rate U.S. rate* 

Oral cavity and pharynx 48 3.2 5.0 20 1.4 1.7 

Digestive system 

Esophagus 41 3.0 5.8 16 1.2 1.5 

Stomach 129 9.1 7.3 93 6.3 3.3 

Respiratory system 

Larynx 15 1.1 2.6 5 0.3 0.5 

Lung and bronchus 562 40.1† 74.2 296 21.4 27.3 

Cervix uteri 126 7.6† 3.1 

Urinary system 

Urinary bladder 18 1.3 5.8 12 0.9 1.7 

Kidney and renal pelvis 80 5.6 4.8 44 3.2 2.2 

Note: Rates per 100,000, age-adjusted to the 1970 U.S. standard population. *1984–1988 U.S. cancer mortality rates for all races. 

†

Denotes a rate significantly different from the U.S. rate. 

Source: Valway 1992. 

and increased for African American women from 1.9 

to 2.2 (CDC 1993a). 

The risks associated with smoking were similar 

for 194 African Americans and 871 whites participating in a 1984–1985 population-based, case-control 

study to assess tobacco use, alcohol use, and other risk 

factors for oral cancer in New Jersey, Atlanta, and two 

areas of California (Table 8) (Day et al. 1993). Calculations of attributable risks showed that the higher incidence of oral cancer among African Americans could 

be largely explained by tobacco and alcohol use. A 

case-control study of oral cancer among North Carolina women in 1975–1978 indicated a similar risk associated with smokeless tobacco use among African 

Americans and whites (Winn et al. 1981). Unfortunately, little information is available on the effects of 

smokeless tobacco use on oral cancer among members 

of the other racial/ethnic groups, even though the use 

of smokeless tobacco is a cause of oral cancer 

(USDHHS 1986b, 1989b). 

Stomach Cancer 

The incidence of stomach cancer in the United 

States is especially high in Asian Americans and Alaska 

Native men and intermediate for African Americans 

(Table 6) (NCI 1996b). The incidence of stomach cancer for persons of Japanese ancestry living in Hawaii is 

lower than for their counterparts in Japan and is increased by cigarette smoking (particularly for those who 

initiated at younger ages) (Nomura et al. 1995). In a 

case-control study conducted in south Louisiana, the 

risk of stomach cancer in African Americans was higher 

among smokers than among nonsmokers; in whites, the 

risk of stomach cancer was only slightly higher among 

smokers than among nonsmokers (Correa et al. 1985). 

In a more recent study, significant increases in stomach 

cancer were observed for African men and women who 

had ever smoked (Burns et al. 1995). 

Health Consequences 155 
 

Surgeon General's Report 

Table 8.	 Odds ratios (ORs) and 95% confidence 

intervals (CIs) for the risk of oral cancer 

associated with cigarette smoking, by 

race/ethnicity and smoking status, 

1984–1985* 

Smoking status 

African 

American _______________ 

OR† ±CI 

White ______________ 

OR† ±CI 

Never smoked 1.0 1.0 

No. of cigarettes 

per day‡ 

1–19 1.2 0.5–2.6 1.2 0.8–1.7 

20–39 2.1 1.0–4.4 2.2 1.6–2.9 

≥ 40 2.8 1.0–7.7 2.8 2.0–4.0 

Years of cigarette 

smoking 

1–19 0.9 0.3–2.4 0.6 0.4–1.0 

20–39 1.6 0.7–3.3 1.9 1.3–2.5 

≥ 40 2.9 1.2–7.2 3.3 2.3–4.6 

Age at smoking 

initiation (years)

 <17 1.8 0.8–3.9 2.0 1.4–2.7 

17–24 1.7 0.8–3.8 1.9 1.4–2.6 

≥ 25 1.2 0.4–3.6 2.2 1.4–3.5 

Years since stopped 

smoking 

0 (never quit) 2.3 1.1–4.7 3.6 2.6–4.8 

1–9 1.1 0.4–3.1 1.1 0.7–1.6 

10–19 0.1 0.0–1.3 1.1 0.7–1.6 

≥ 20 0.3 0.1–1.7 0.6 0.3–0.9 

*Data from four population-based cancer registries in 

Los Angeles County and Santa Clara and San Mateo 

Counties near San Francisco-Oakland, metropolitan 

Atlanta, and the state of New Jersey. 

†

ORs are adjusted for alcohol consumption, gender, age, 

study location, and respondent status and are relative to persons who never smoked. 

‡

Usual number of cigarettes smoked daily when the 

persons smoked. 

Source: Day et al. 1993. 

Urinary Bladder Cancer 

The incidence of urinary bladder cancer in the 

United States is highest for whites (Table 6) (NCI 

1996b). Among men, mortality is highest for whites; 

among women, mortality is highest for African Americans (Tables 2 and 6) (NCI 1996b). Differences in bladder cancer risk associated with cigarette smoking for 

African Americans and whites have been examined in 

several case-control studies (Table 9), including the 

ongoing study conducted by the American Health 

Foundation (Harris et al. 1990), a population-based 

study conducted in the Detroit metropolitan area 

(Burns and Swanson 1991), and a population-based 

study carried out through SEER registries in 1978 

(Hartge et al. 1993). In the American Health Foundation study, investigators found that although cigarette 

smoking was a significant risk factor for bladder cancer among both whites and African Americans, the 

data suggested a steeper exposure-response relationship among whites (with significant increased risk 

beginning at exposures of 20 pack-years) than among 

African American men (with increased risk beginning 

only after 60 pack-years). However, in a multivariate 

analysis of the data for men, the risk of bladder cancer 

did not differ by race. The other two studies showed 

similar findings for both whites and African Americans in the association between cigarette smoking and 

bladder cancer. In a smaller case-control study in Orange County, California, no significant interactions 

were found between smoking and race/ethnicity 

among whites, Hispanics, Asian Americans, or Pacific 

Islanders (Anton-Culver et al. 1993). Thus, information currently available suggests that smoking increases the risk of bladder cancer in a similar fashion 

among both whites and African Americans. In a cohort study of 7,995 Japanese American men who were 

living in Hawaii, the risk of bladder cancer was 2.9 

times higher in current smokers than in nonsmokers 

(Chyou et al. 1993). 

Aromatic amines, such as 4-aminobiphenyl, are 

considered causative chemical agents in cigarette 

smoke-induced bladder cancer (Bartsch et al. 1993). As 

with other potential carcinogens in tobacco smoke, 

aromatic amines require metabolic activation before 

interacting with DNA (Miller and Miller 1981). A competing chemical pathway (i.e., acetylation) exists and 

serves as a detoxification mechanism. Genotyping 

studies have characterized several variant alleles of the 

N-acetyltransferase gene, which can result in different rates of chemical acetylation. People who are slow 

acetylators have increased risk for bladder cancer 

(Hein 1988). Bell and colleagues (1993) determined 

156 Chapter 3 
 

_____________________ ______________________

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 9.	 Odds ratios for the risk of urinary bladder cancer associated with smoking, by gender, race/ 

ethnicity, and smoking status 

Men	 Women 

Reference, study type, 

and year 

Smoking 

status 

African 

American 

African 

White American White 

Harris et al. 1990 

Multicenter, hospital-based, 

1973–1985 

Never 1.0 1.0 1.0 1.0 

Former 1.6 2.1 1.3 

Current 2.0 3.2 3.9* 3.2 

Burns and Swanson 1991 

Detroit, population-based 

Never 1.0 1.0 1.0 1.0 

Ever 3.0 2.3 3.8 2.4 

Pack-years 

< 30	 1.9 1.5 3.1 1.7 

30–59.9 4.0 2.6 3.8 2.9 

60–89.9 4.7 2.7 5.0 3.5 

> 90 4.8 3.0 5.2 2.7 

Hartge et al. 1993 

SEER† registries, 

population-based, 1978 

Never 1.0 1.0 1.0 1.0 

Former 

Cigarettes smoked 

< 20 per day 1.6 1.3 3.6 2.0 

≥ 20 per day 1.8 1.9 5.0 1.3 

Current 

Cigarettes smoked 

< 20 per day 2.2 2.1 1.7 2.0 

≥ 20 per day 4.5 3.0 2.1 3.1 

*Ever smokers. 

†

National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. 

that 41 percent of African Americans and 55 percent 

of whites were slow acetylators. A phenotyping study 

also found the highest percentage of slow acetylators 

among whites (54 percent), compared with African 

Americans (34 percent) and Asians (14 percent) (Yu et 

al. 1994). 

In the 1994 study by Yu and colleagues, 

slow acetylators had higher levels of 3- and 

4-aminobiphenyl-hemoglobin adducts, regardless of 

race and level of smoking (Yu et al. 1994). For African 

Americans, Asians, and whites, however, the levels of 

3- and 4-aminobiphenyl-hemoglobin adducts increased proportionately more for cigarette smokers 

compared with nonsmokers than for slow acetylators 

compared to rapid acetylators. In a subsequent study 

by Yu and colleagues (1995), the slow acetylation 

phenotype combined with the null genotype of the 

gene (GSTM1) for a phase II detoxification enzyme 

(glutathione S-transferase) resulted in higher levels of 

3- and 4-aminobiphenyl-hemoglobin adducts than did 

lower risk profiles (i.e., rapid acetylator and/or at least 

one functional GSTM1 gene allele). The highest risk 

profile was seen in 27 percent of whites, 15 percent of 

African Americans, and 3 percent of Asians. 

Several studies show that the highest levels of 

risk are experienced by smokers, because high levels 

of exposure to tobacco smoke overwhelm the various 

phenotypic traits. The differences in risks for various 

detoxification and activation pathways appear to be 

most significant among persons who did not smoke 

or who smoked at very low levels (Yu et al. 1994, 1995; 

Landi et al. 1996). 

Health Consequences 157 
 

Surgeon General's Report 

Chronic Obstructive Pulmonary Disease 

In addition to causing lung cancer, tobacco smoking also causes several non-malignant diseases of 

the lung and increases the frequency of respiratory 

symptoms and illnesses (USDHHS 1989b, 1990). 

Chronic obstructive pulmonary disease (COPD) is 

a clinical term applied to persons with a permanent 

airflow obstruction associated with significant impairment (Samet 1989; USDHHS 1989b). Cigarette smokers with COPD have impaired breathing as a result of 

emphysema (air space enlargement and destruction) 

and damage to the airways (USDHHS 1984). These 

smokers also may have chronic bronchitis, which is 

the term used by epidemiologists and clinicians for 

chronic sputum production. 

Longitudinal studies show that the development 

of COPD follows sustained excessive loss of ventilatory function of the lung caused by cigarette smoking 

(USDHHS 1984, 1990). The rate at which ventilatory 

function declines tends to increase with the amount 

smoked and to revert to the rate associated with aging 

after smoking cessation (USDHHS 1990). The frequency of chronic bronchitis is similarly related to 

smoking pattern. 

African Americans 

Data from several national surveys have been 

used to compare the prevalence of COPD among African Americans and whites. McWhorter and colleagues 

(1989) used data from the 1971–1975 National Health 

and Nutrition Examination Survey (NHANES I) and 

the 1982–1984 NHANES I Epidemiologic Follow-up 

Study (NHEFS) to determine the prevalence of COPD 

among 14,404 adults aged 25–74 years. African American race/ethnicity was associated with a lower risk 

for having COPD; 6.2 percent of whites and 3.2 percent of African Americans had COPD. 

In the 1990 NHIS, the prevalence of self-reported 

chronic bronchitis was 55.2 per 1,000 African Americans aged 45–64 years and 42.7 per 1,000 African 

Americans aged 65 years and older (USDHHS 1991). 

The prevalence of self-reported emphysema was 3.6 

per 1,000 middle-aged African Americans and 41.5 per 

1,000 older African Americans. Compared with African Americans, whites in both age groups reported 

higher prevalences of chronic bronchitis (59.7 for those 

aged 45–64 years and 73.8 for those aged 65 years and 

older) and emphysema (13.8 for those aged 45–64 years 

and 46.1 for those aged 65 years and older). However, 

self-reports of chronic bronchitis and emphysema, 

without further validation, are probably subject to substantial misclassification. 

African Americans are also less likely than whites 

to die of COPD (Evans et al. 1987; NCHS 1991). Evans 

and colleagues (1987) found that in 1982, the ageadjusted COPD death rate was 16.6 per 100,000 whites 

and 12.8 per 100,000 African Americans. Data for 1986– 

1988 also show lower death rates from COPD among 

African Americans than among whites (Desenclos and 

Hahn 1992). More recent data (Table 2) show that African American men have higher death rates (17.6) for 

chronic airway obstruction than men in the other three 

racial/ethnic minority groups, although their rates are 

lower than rates among white men (20.4). The same 

pattern is also evident for deaths due to bronchitis and 

emphysema. The rate of COPD mortality is unexpectedly low among African Americans, given their high 

prevalence of smoking and related high lung cancer 

rates. The reasons for this discrepancy remain to be 

explored. However, whites are more likely than African Americans to have ever smoked and to be former 

smokers (see Table 37 in Chapter 2). Mannino and 

colleagues (1997) have observed that death rates from 

obstructive lung disease relate to rates of ever smoking. These authors suggest that the differences in the 

race- and gender-specific relative rankings for obstructive lung disease and lung cancer may be because 

long-term former smokers are more likely to develop 

obstructive lung disease than lung cancer. 

American Indians and Alaska Natives 

Little information is available on the occurrence 

of COPD among American Indians and Alaska 

Natives. In a 1987 survey of approximately 6,500 

American Indians and Alaska Natives aged 19 years 

and older, 2.4 percent of men and 1.4 percent of women 

reported having emphysema, compared with 2.7 percent of men and 2.3 percent of women in the general 

U.S. population (Johnson and Taylor 1991). Rhoades 

(1990) studied hospitalization and death rates for 

COPD in American Indians and Alaska Natives. 

Although the death rates for COPD were lower than 

from other competing causes, such as chronic liver 

disease, diabetes, and injuries, the hospitalization rates 

for COPD exceeded those for cancer and tuberculosis. 

158 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Additionally, hospitalization rates and death rates for 

COPD varied widely between geographic regions. The 

contribution of COPD to hospitalization rates ranged 

from 1.6 percent in the Navajo IHS area to 5.1 percent 

in the Bemidji area; COPD death rates per 100,000 

ranged from 1.7 in the Albuquerque area to 10.3 in the 

Billings area (Rhoades 1990). 

Between 1992 and 1994, COPD death rates among 

American Indian men were approximately two-thirds 

the rates among whites (Table 2). Data from the Alaska 

area indicate that from 1979 through 1986, COPD death 

rates per 100,000 were 31.6 for Alaska Native men, 

compared with 40.3 for white men in Alaska and 38.3 

for men in the United States as a whole (Coultas et al. 

1994). The COPD death rates per 100,000 were 22.3 

for Alaska Native women, compared with 34.8 for 

white women in Alaska and 18.6 for women in the 

United States as a whole. Similarly, death rates for 

COPD in New Mexico (Samet et al. 1988b) reflect the 

nationwide pattern of lower rates of death among 

American Indians compared with whites and are consistent with the lower smoking prevalence among 

tribes in the southwestern United States (Sugarman et 

al. 1992). The high rates of COPD among Alaska 

Natives are probably related to the fact that rates of 

smoking among Alaska Natives are higher than rates 

among American Indians elsewhere, particularly in the 

Southwest. 

Asian Americans and Pacific Islanders 

Information on COPD morbidity and death 

among Asian Americans and Pacific Islanders is sparse. 

National mortality data indicate that the prevalence 

of deaths from bronchitis and emphysema is lower in 

this group than among African Americans and whites 

(Table 2); the death rate from chronic airways obstruction is lowest for Asian Americans and Pacific Islanders. Data from California show that from 1986 through 

1987, the overall prevalence of COPD deaths among 

“Asian and other” persons was lower than among 

whites but varied widely for specific Asian American 

and Pacific Islander subgroups (Asian American 

Health Forum, Inc. 1990). 

One of the oldest studies of Asian Americans— 

the Honolulu Heart Study, conducted in 1965—provides 

valuable age-related information on smoking and lung 

function among Japanese Americans. Of the 6,346 

Japanese American men aged 46–68 years who underwent spirometric testing, 48 percent were current cigarette smokers, 25 percent were former smokers, and 

27 percent had never smoked (Marcus et al. 1988). 

Airflow obstruction was found in 11.7 percent of the 

participants. The prevalence of airflow obstruction 

increased with age and with the amount smoked. For 

most age and smoking categories, the prevalence of 

airflow obstruction was lower among Japanese American men than among white men from Connecticut 

participating in the same study (Beck et al. 1981). 

In another recent analysis of data from the Honolulu Heart Program, Japanese American men who 

continued to smoke showed steeper rates of decline in 

forced expiratory volume after one second (FEV1

), a 

measure of pulmonary function, compared with never 

smokers. Among continuing smokers, FEV1 decline 

was significantly associated with duration of smoking. Additionally, the rate of decline in FEV1

 among 

former smokers became more like that of persons who 

had never smoked (Burchfiel et al. 1995), consistent 

with previous reports on the benefits of quitting smoking (USDHHS 1990). In another analysis of data from 

the same study, Sharp and colleagues (1994) found that 

a diet composed of large amounts of fish may protect 

the lungs against damage from cigarette smoking. 

However, fish consumption was not associated with 

pulmonary function at higher levels of cigarette smoking (>30 cigarettes/day). 

Hispanics 

In the 1982–1984 Hispanic Health and Nutrition 

Examination Survey (HHANES), Puerto Ricans (2.9 

percent) had a higher prevalence of reported chronic 

bronchitis than Mexican Americans (1.7 percent) or 

Cuban Americans (1.7 percent) (Bang et al. 1990). 

Chronic airflow obstruction (assessed using spirometry) was present in less than 1 percent of Hispanic 

adults surveyed in a New Mexico community (Samet 

et al. 1988a). Similarly, investigators who surveyed 

Mexican Americans in Tucson, Arizona, found a relatively low prevalence of physician-diagnosed COPD 

or related diagnoses (Di Pede et al. 1991). 

COPD has been reported to occur less frequently 

among Hispanics than among whites. Surveys in New 

Mexico have shown, for example, that physiciandiagnosed chronic bronchitis or emphysema is less 

common among Hispanics than among whites (Samet 

et al. 1982, 1988a). Death rates from chronic obstructive lung diseases and allied conditions are also lower 

among Hispanics than among whites (Tables 2 and 4). 

Mortality data for New Mexico indicate that between 

1958 and 1982, Hispanic men had a lower death 

rate from COPD than white men; however, from 

1958 through 1982, the death rate from COPD rose 

Health Consequences 159 
 

Surgeon General's Report 

steeply among Hispanic men—from 5.0 per 100,000 in 

1958–1962 to 30.1 per 100,000 in 1978–1982 (Samet et al. 

1988b). During this same time, COPD death rates increased among Hispanic women but remained comparable to rates among white women (Samet et al. 1988b). 

Little information is available on the risk of 

COPD among Hispanic smokers. In a 1979 respiratory disease survey of Hispanic and white residents 

of New Mexico’s Bernalillo County, Samet and 

colleagues (1982) found that race/ethnicity was not a 

significant predictor of current or previous physiciandiagnosed chronic bronchitis and emphysema and that 

no significant interaction existed between race/ 

ethnicity and cigarette smoking. Hispanic ethnicity 

also was not a significant predictor of the symptoms 

of chronic cough, chronic phlegm, or persistent 

wheeze. Similarly, the results of a survey of Hispanics 

Coronary Heart Disease 

and whites in Tucson indicated that race/ethnicity was 

not a significant determinant of respiratory symptoms, 

after survey data were adjusted for cigarette smoking 

(Di Pede et al. 1991). However, a recent cross-sectional 

study of urban pregnant women indicated that the 

prevalence of either doctor-diagnosed asthma or persistent wheeze without asthma was lower among a heterogenous Hispanic population than among white 

women of similar socioeconomic background (these 

data were adjusted for cigarette smoking status, family history of asthma, educational level, household 

exposure to pets, and level of lung function). The authors did not conclude that their data provided evidence of biological protection from wheeze syndromes. 

An almost fivefold excess risk of persistent wheeze was 

detected in the total population of urban women who 

are current smokers (David et al. 1996). 

In 1994, cardiovascular diseases, comprising a 

diverse group of disorders including coronary heart 

disease (CHD), hypertension, stroke, and rheumatic 

heart disease, caused approximately 940,000 deaths in 

the United States (NCHS 1996a). The occurrence of 

specific cardiovascular diseases and their risk factors 

varies widely among the different racial/ethnic minority groups. Of the cardiovascular diseases, CHD 

is the single largest cause of death; it results in approximately 480,000 deaths annually in the United States. 

This section of the report focuses on CHD, which is 

also termed coronary artery disease or ischemic heart 

disease (IHD). 

Coronary artery disease results from atherosclerosis of coronary arteries. Anatomical lesions become 

evident in young adults and are usually clinically 

manifest in the fifth through seventh decades as 

angina pectoris, myocardial infarction, and sudden 

cardiac death (Enos et al. 1986; Strong 1986). In this 

chapter, these clinical manifestations of coronary 

artery disease are collectively termed CHD. 

Numerous non-modifiable and modifiable risk 

factors contribute to the development of CHD. The 

non-modifiable factors include aging, gender (men 

have greater risk), and family history of CHD. The 

major risk factors that are potentially modifiable 

include hypertension, cigarette smoking, obesity, 

hypercholesterolemia, diabetes mellitus, and physical 

inactivity (Smith and Pratt 1993). The 1983 Surgeon 

General’s report on smoking and health concluded that 

“Cigarette smoking should be considered the most 

important of the known modifiable risk factors for 

coronary heart disease in the United States” (USDHHS 

1983, p. iv). 

African Americans 

The first population-based epidemiological investigations of cardiovascular diseases in the United 

States that included substantial numbers of African 

American and white participants began in 1960 in 

Evans County, Georgia, and Charleston, South Carolina (Saunders 1991). Since 1960, follow-up data for 

these cohorts and a number of other epidemiological 

studies have provided information on the combined 

effects of race/ethnicity and various risk factors for 

cardiovascular disease. Consistent with findings for 

the general population, cigarette smoking increased 

risk of death from CHD among African Americans 

(Hames et al. 1993; Keil et al. 1995). 

Tyroler and colleagues (1984) examined deaths 

from CHD among the Evans County men, who were 

followed from 1960 through 1980, and found that the 

overall rate of death from CHD was lower among African Americans than among whites, with a ratio of 

0.86. For current and former smokers, the probability 

160 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

of dying from all causes and from CHD was higher 

among whites with a low-socioeconomic status (on the 

basis of occupation, education, and source of income 

of the head of household) than among their African 

American counterparts. However, the analysis did not 

control for the number of cigarettes smoked, and the 

data were limited because of the small number of CHD 

deaths (31) among African Americans. 

In the Charleston Heart Study of CHD death rates 

between 1960 and 1990, Keil and colleagues (1993) 

found that the age-adjusted, African Americanto-white death rate ratios were 0.90 for men and 1.2 

for women. After controlling for age and other cardiac risk factors, the researchers found that smoking 

was associated with a slightly higher risk of dying of 

CHD among African American men than among white 

men. White women had a slightly higher risk of 

dying of CHD than did African American women. 

These racial/ethnic group differences were not tested 

for statistical significance, however. 

Other investigations that provide information on 

the risks for CHD and the modification of the effects 

of smoking, by race/ethnicity, include the Cancer Prevention Study I (CPS-I) (Garfinkel 1984), the NHEFS 

(Cooper and Ford 1992), the National Mortality 

Followback Survey (NMFS) (DeStefano and Newman 

1993), and the ongoing study of Kaiser Permanente 

enrollees (Friedman et al. 1997). As part of the CPS-I, 

death patterns in the original cohort of one million 

people were described for 1959–1972. The observedto-expected death rate ratios from CHD among African Americans and whites followed the same pattern 

as nationwide vital statistics described previously. 

Overall, the African American-to-white ratios of CHD 

deaths were 0.78 for men and 1.07 for women. Stratified analyses, by gender, of any effects that the amount 

of cigarettes smoked might have on CHD deaths 

showed little difference between African Americans 

and whites. 

Participants in the NHANES I, conducted between 1971 and 1975, were reexamined between 1982 

and 1984 as part of the NHEFS (Cooper and Ford 1992). 

Of the 12,599 participants in the follow-up survey, 

10,741 were white and 1,858 were African American. 

The study showed that cumulative incidence rates of 

fatal CHD were higher among African Americans (6.2 

percent of men and 3.7 percent of women) than among 

whites (5.6 percent of men and 2.6 percent of women). 

In contrast, cumulative incidence rates of nonfatal 

CHD were higher among whites (7.0 percent of men 

and 4.7 percent of women) than among African Americans (5.0 percent of men and 3.9 percent of women). 

The risk of new CHD events associated with cigarette 

smoking was similar among whites and African Americans. These results, however, are limited by the small 

number of new CHD events among African Americans and the low proportion (approximately 50 percent) of respondents for whom smoking information 

was collected at baseline. 

In a case-control study of CHD deaths among 

African Americans and whites, DeStefano and 

Newman (1993) used data from the 1986 NMFS to identify case subjects (n = 803) and 1988 data from the 

BRFSS to identify control subjects (n = 25,398). When 

they compared the risk of death among smokers vs. 

persons who have never smoked (men aged 25–44 

years and women aged 25–54 years), the investigators 

found that among persons without diabetes, African 

American smokers had a lower relative risk for CHD 

death than white smokers. However, the 95 percent 

confidence intervals associated with these odds ratios 

overlapped each other—an indication that the difference in risk was not statistically significant. In the 

Kaiser study, the risk of death from CHD has varied 

among African Americans and whites, but small numbers limit interpretation of these findings (Friedman 

et al. 1997). 

American Indians and Alaska Natives 

Most of the available data on CHD among American Indians and Alaska Natives have originated from 

studies of selected tribes, as reviewed by Young (1994). 

Investigations of heart disease in southwestern American Indians and Alaska Natives conducted several 

decades ago showed a low prevalence of CHD relative to the U.S. population and other racial/ethnic 

groups (Welty and Coulehan 1993). In a descriptive 

study of CHD deaths occurring from 1948 through 

1952 among the Navajos, Smith (1957) found that the 

standardized death rate ratios for CHD among the 

Navajos compared with whites were 0.10 for men and 

0.12 for women. Since then, numerous other regional 

investigations of CHD deaths and the incidence of 

CHD in other tribes of the United States and Canada 

have been reported. Overall, for studies conducted in 

the 1950s and 1960s, the ratios of CHD death rates 

among American Indians and Alaska Natives compared with nationwide rates have ranged from 0.1 to 

0.5. An analysis of death statistics from the NCHS 

showed that crude CHD death rates for individuals 

classified as American Indians, Eskimos, or Aleuts 

declined from 100 per 100,000 in 1969–1971 to 67 per 

100,000 for the years 1979–1981 (Gillum 1988). A review of New Mexico’s vital statistics for 1958–1982 

indicates that for American Indian men, CHD death 

Health Consequences 161 
 

Surgeon General's Report 

rates peaked at 101.7 per 100,000 between 1968 and 

1972 and fell to 76.6 per 100,000 between 1978 and 1982 

(Becker et al. 1988). For American Indian women, the 

CHD death rate peaked at 63.0 per 100,000 between 

1963 and 1967 and declined to a low of 28.3 per 100,000 

between 1978 and 1982. 

In a recent analysis of mortality data for 1992– 

1994 (Table 2), the rate of death due to CHD was lower 

among American Indian and Alaska Native men 

(100.4) and women (45.9) than among white men 

(132.5) and women (62.9). The ratio of CHD death rates 

among American Indians and Alaska Natives compared with whites was .76 for men and .73 for women. 

The fact that these ratios are higher than ratios from 

earlier studies suggests that CHD deaths among 

American Indians and Alaska Natives may be increasing (Welty and Coulehan 1993; Young 1994). 

Risk factors for cardiovascular disease were investigated recently in a large multi-tribal study of 

American Indians. The results showed that mean levels of total, low density lipoprotein, and high density 

lipoprotein cholesterol were lower in American Indians than in the U.S. general population. Prevalence of 

hypertension, non-insulin dependent diabetes mellitus, and obesity were very high, but varied considerably among tribes and geographic regions (Welty et 

al. 1995). A second study found that levels of serum 

cholesterol were lower in American Indian smokers 

who attended a stop smoking clinic than in African 

American and white smokers from population-based 

samples (Folsom et al. 1993). However, fibrinogen levels and the prevalence of abdominal obesity were 

higher in American Indian smokers than in African 

Americans and whites. 

The IHS is another source of nationwide and regional health statistics on CHD deaths. Because the 

mortality data in IHS reports combine all cardiovascular diseases under “diseases of the heart” (IHS 

1994b), this information cannot be compared directly 

with CHD data from other sources. Between 1989 and 

1991, diseases of the heart accounted for 21.9 percent 

of deaths in all IHS areas, with a crude death rate 

of 115.1 per 100,000 (IHS 1994b). These data indicate 

cardiovascular diseases were the leading cause of 

death among American Indians. However, because 

Indian race/ethnicity was underreported on death certificates in several IHS areas, including California and 

Oklahoma as well as Portland, Oregon, this death rate 

may be incorrect. 

Death rates from heart diseases vary widely 

among people in the 12 IHS areas. From 1989 through 

1991, the rate of death from heart diseases per 100,000 

was lowest in the Albuquerque area (88.0) and highest in the Aberdeen area (249.0) (IHS 1994a). These 

wide variations in deaths from diseases of the heart 

parallel the wide variations in the prevalence of cigarette smoking among the various tribes (Sugarman et 

al. 1992; Coultas et al. 1994) (see also Chapter 2). For 

example, in a 1985–1988 survey of adult American Indians in the southwestern United States, 18.1 percent 

of men and 14.7 percent of women reported current 

smoking, compared with 48.4 percent of men and 57.3 

percent of women in the Plains states (Sugarman et al. 

1992). 

Data to assess the influence of tobacco use on 

the risk of cardiovascular disease among American 

Indians are extremely limited. One study has shown 

that cigarette smoking increases the risk for CHD 

among American Indians, after adjustment for other 

risk factors (Howard et al. 1995). In fact, most studies 

presented in this section describe cardiovascular disease morbidity and mortality without ever assessing 

the influence of tobacco use. Nevertheless, cardiovascular disease is the leading cause of death among 

American Indians and Alaska Natives (NCHS 1996b), 

and tobacco use is an important risk factor for this 

disease. More studies are needed to evaluate the independent effect of tobacco use on the risk of cardiovascular disease among American Indians and Alaska 

Natives. 

Asian Americans and Pacific Islanders 

Limited data are available on risk factors and 

CHD among Asian Americans and Pacific Islanders 

in the United States (Yu 1991). A recent study of nationwide mortality indicated that Asian Americans and 

Pacific Islanders have lower rates of death from CHD 

than whites (Table 2). 

In an analysis of 1980 death rates in Los Angeles 

County, Frerichs and colleagues (1984) found that the 

age- and gender-adjusted death rates for cardiovascular diseases varied widely among Asian Americans and 

Pacific Islanders. Koreans had the lowest rate per 

100,000 (82), and Japanese had the highest rate (162). 

These rates were substantially lower than the overall 

rate for the county population, with rate ratios of 0.26 

for Koreans and 0.52 for Japanese. Specific data on 

CHD deaths and cigarette smoking prevalence were 

not available. 

In another study, Reed and colleagues (1983) used 

death records from Hawaii to describe age-adjusted, 

gender-specific, and racial- and ethnic-specific rates 

of CHD deaths occurring from 1940 through 1978. For 

all racial/ethnic minority groups, CHD death rates 

were higher among men than among women. Death 

162 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

rates and the temporal trends in deaths varied widely 

between the different groups, with the highest death 

rates among Native Hawaiians and the lowest among 

Japanese. Filipino men had the greatest increase in 

CHD death rates, surpassing the rates for whites in 

1978. Although most of the other groups had declines 

in CHD death rates between 1960 and 1970, CHD death 

rates for Native Hawaiian men remained level. 

In 1965, three cohorts of Japanese men were assembled in Japan, Honolulu, and San Francisco to investigate the differences in CHD deaths observed 

among Japanese men living in the three locales (Worth 

et al. 1975; Yano et al. 1988). From 1965 through 1972, 

Worth and colleagues (1975) found that age-specific 

death rates were highest among the San Francisco men, 

intermediate among those living in Honolulu, and lowest among those living in Japan. For example, among 

men 60–64 years of age, the annual CHD death rates 

per 1,000 were 4.9 in San Francisco, 3.9 in Honolulu, 

and 2.1 in Japan. Mortality data for 1965–1980 indicate that the age-adjusted CHD death rate ratio for men 

in Honolulu compared with men in Japan was 1.4 

(Yano et al. 1988). The age-adjusted mean levels of 

most CHD risk factors, including cigarette smoking 

(measured in cigarette-years), were also higher among 

Honolulu men. After adjusting for these risk factors, 

the rate ratio for CHD declined to 1.17, indicating that 

more than half of the elevated CHD death rate was 

due to the higher mean levels of CHD risk factors 

among Honolulu men. 

In the Honolulu Heart Program cohort, composed of 7,705 Japanese men 45–68 years of age living 

in Hawaii who had no evidence of CHD at enrollment 

between 1965 and 1968, numerous analyses were conducted to further examine predictors of CHD incidence 

and death (Reed et al. 1982, 1987; Yano et al. 1984; 

Benfante et al. 1991). A higher level of acculturation 

was found to be associated with CHD risk factors and 

incidence during the 1971–1979 follow-up (Reed et al. 

1982). Men who were primarily Japanese in culture 

smoked an average of seven cigarettes per day, 

whereas men who were more acculturated smoked an 

average of 11 cigarettes per day. A similar pattern was 

seen for total CHD incidence, which was highest 

among the men who were more acculturated (62 per 

1,000) and lowest among the men who were primarily 

Japanese in culture (35 per 1,000). 

Yano and coworkers (1984) conducted detailed 

analyses of the relationship between risk factors and 

the incidence of CHD during a 10-year period, beginning after the enrollment period (1965–1968). Systolic 

blood pressure, number of cigarettes smoked, and cholesterol level were all independently associated with 

the occurrence of all CHD events. Alcohol consumption was found to be a protective factor. Subsequent 

analyses of 20-year follow-up data from the same study 

showed that cigarette smoking was independently 

associated, in a dose-response manner, with increased 

risk of CHD (fatal or nonfatal) and aortic aneurysm 

(Goldberg et al. 1995). The risk for angina was elevated 

in persons who smoked more than 20 cigarettes per 

day. Another analysis suggested that high levels of 

fish intake might limit the increased risk among heavy 

smokers, although these findings should be considered preliminary (Rodriguez et al. 1996). In addition, 

cigarette smoking was found to be independently 

associated with increased prevalence of myocardial 

lesions in Japanese men with minimal evidence of coronary atherosclerosis at autopsy (Burchfiel et al. 1996). 

Hispanics 

Because of incomplete data, the NCHS reported 

data from 1985 death certificates on decedents of Hispanic origin for only 17 states and the District of 

Columbia (NCHS 1996b). By 1990, data for 47 states 

and the District of Columbia were reported. The NCHS 

estimated that the 1990 reporting area encompassed 

99.6 percent of the U.S. Hispanic population (NCHS 

1996b). In 1993 and 1994, only Oklahoma did not provide information on Hispanic origin (NCHS 1996a,b). 

Between 1992 and 1994, the overall rate of death 

from CHD in the United States was lower among Hispanics than among whites (Table 2). Among the various Hispanic subgroups, Puerto Rican men had the 

highest death rates per 100,000 (118.6); similarly, CHD 

death rates among Puerto Rican women (67.3) were 

higher than among Mexican (44.2) and Hispanic (42.4) 

women. 

Nationwide death rates among Hispanics and 

whites have been estimated by using data collected 

by the U.S. Bureau of the Census as part of the Current Population Survey (CPS) (Sorlie et al. 1993). 

Baseline interview data were obtained between 1973 

and 1985 from approximately 40,000 Hispanics and 

660,000 non-Hispanics aged 25 years and older. Death 

rates for these two groups were ascertained up to nine 

years after the initial interview through the National 

Death Index. Age-adjusted death rate ratios for 

CHD were lower among Hispanics than among nonHispanics (0.60 for men and 0.75 for women). Further 

details for the different Hispanic subgroups were 

not provided. 

In addition to nationwide data on the occurrence 

of CHD among Hispanics, regional studies have been 

conducted in California (Schoen and Nelson 1981; 

Health Consequences 163 
 

Surgeon General's Report 

Frerichs et al. 1984), Colorado (Rewers et al. 1993), New 

Mexico (Buechley et al. 1979; Becker et al. 1988), and 

Texas (Stern and Gaskill 1978; Stern et al. 1987; Mitchell 

et al. 1991; Goff et al. 1993). In general, these investigations have consistently shown that Hispanic men 

have lower CHD death rates than white men, although 

the Colorado study found little evidence for lower 

CHD death rates among Hispanics without diabetes 

(Rewers et al. 1993). 

The prevalence of angina was also found to be 

lower among Hispanics than among whites in a review of data from a sample of Mexican Americans 

participating in the 1982–1984 HHANES and of whites 

surveyed in the 1976–1980 NHANES II (LaCroix et al. 

1989). Prevalence rates based on self-reports were 2.8 

percent among Mexican American men and 3.9 percent among white men, and they were 5.4 percent 

among Mexican American women and 6.3 percent 

among white women. As with African Americans, no 

significant differences were observed in the distribution of cardiovascular disease risk factors among Mexican Americans with and without self-reported angina. 

The results of this survey were limited by the lack of 

smoking-specific analyses for Mexican Americans. 

Several investigators also have examined the cardiovascular disease risk factor profiles of Hispanics 

(Mitchell et al. 1991; Shea et al. 1991; Winkleby et al. 

1993). Shea and colleagues (1991) analyzed 1989 BRFSS 

data on 636 Hispanics, most of whom were Puerto 

Ricans, Dominicans, and Cubans living in New York 

City. Although the overall risk factor profile was high 

among these Hispanic subgroups, the prevalence of 

current cigarette smoking varied by level of education. 

Mitchell and colleagues (1991) obtained information 

Cerebrovascular Disease 

on cardiovascular disease risk factors from 5,148 

subjects, including 3,281 Mexican Americans, who 

participated in the San Antonio Heart Study from 1979 

through 1988. The overall risk profiles were higher 

among Mexican Americans. For men of all ages, the 

prevalence of current smoking was higher among 

Mexican American men (36.7 percent) than among 

white men (30.4 percent). For women of all ages, however, the prevalence of current smoking was lower 

among Mexican American women (21.0 percent) than 

among white women (26.8 percent). For both men and 

women, the number of cigarettes smoked per day was 

consistently lower among Mexican Americans than 

among whites. More recently, Winkleby and colleagues (1993) examined the cardiovascular disease 

risk profiles of 756 Hispanics and 756 whites participating in California surveys from 1979 through 1990. 

Hispanics and whites were matched by age, gender, 

educational level, city of residence, and time of survey. Whites had a higher prevalence of smoking (34.2 

percent) than Hispanics (24.0 percent), and they smoked 

more cigarettes per day (19.7) than Hispanics (11.4). 

Few investigators have compared the risk of 

smoking-related CHD between Hispanics and members of other racial/ethnic groups. Mitchell and coworkers (1991) determined the 1979–1988 prevalence 

of myocardial infarction among 3,281 Mexican Americans and 1,867 whites who participated in the San 

Antonio Heart Study. On the basis of either electrocardiograms or self-reports, the risk of myocardial infarction among Mexican Americans compared with 

whites was 24 percent lower for men but 40 percent 

higher for women. Race/ethnicity did not appear to 

modify the risk for myocardial infarction. 

Cerebrovascular disease is a major cause of 

mortality and morbidity in the United States every 

year. In 1994, a total of 153,306 deaths in the United 

States were caused by cerebrovascular disease (NCHS 

1996a). 

Stroke, the major form of cerebrovascular disease, 

results from an interruption of the arterial blood supply to the central nervous system, primarily the brain. 

Most commonly, the interruption of the arterial blood 

supply results from an occlusion of an artery in the 

brain by a thrombus, which may have resulted from 

atherosclerosis or blood clots from a diseased heart. A 

less common mechanism for development of stroke 

is rupture of a blood vessel in the brain. Other diagnoses under the general rubric of cerebrovascular 

disease include transient cerebral ischemia and cerebral arteriosclerosis. 

As for CHD, risk factors for stroke may be 

divided into non-modifiable and modifiable characteristics. The non-modifiable factors include aging, 

gender, and family history of stroke. The major risk 

factors that are potentially modifiable include hypertension, hypercholesterolemia, diabetes mellitus, cigarette smoking, and heart disease (USDHHS 1989b). 

164 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

African Americans 

The rate of death from cerebrovascular disease 

in the United States is higher among African Americans than other racial/ethnic groups and whites (Table 

2). For 1992–1994, the rate of death (per 100,000 population) from cerebrovascular disease was twice as high 

among African American men (53.1) as among white 

men (26.3) and almost twice as high among African 

American women (40.6) as among white women (22.6). 

Similar patterns have been observed in studies 

of persons belonging to health plans. Klatsky and colleagues (1991) determined the incidence of hospitalization for cerebrovascular disease among 74,096 

whites and 33,041 African Americans who were members of a prepaid health plan in northern California 

from 1978 through 1984. The relative risks for hospitalization for hemorrhagic cerebrovascular disease, 

cerebral thrombosis, and nonspecific cerebrovascular 

disease were higher among African Americans than 

among whites. Because hypertension is the strongest 

risk factor for stroke, the high prevalence of hypertension among African Americans partially explains this 

pattern (Braithwaite and Taylor 1992). Despite limited data on the link between smoking and stroke 

among African Americans, the high rate of cigarette 

smoking among African Americans (see Chapter 2) 

clearly appears to have played a significant role in elevating the risks of stroke in this population (USDHHS 

1983). 

American Indians and Alaska Natives 

In recent years, age-adjusted death rates for cerebrovascular disease were slightly lower among American Indian and Alaska Native men and women than 

among white men and women (Table 2). For example, 

from 1992–1994, the age-adjusted death rate per 

100,000 population for cerebrovascular disease was 

23.9 for American Indian and Alaska Native men, 26.3 

for white men, 21.1 for American Indian and Alaska 

Native women, and 22.6 for white women. 

Young’s (1994) recent review of the literature indicates that few investigations have focused on cerebrovascular disease among American Indians or 

Alaska Natives. Middaugh (1990) found little difference between the death rate from cerebrovascular disease among Alaska Natives and persons of other race/ 

ethnicities, with death rate ratios of 1.13 for men and 

1.03 for women. In a review of 1958–1987 vital statistics data from New Mexico, Kattapong and Becker 

(1993) observed lower rates of death from cerebrovascular disease among American Indians than among 

Hispanics and whites. For American Indian men, cerebrovascular disease death rates per 100,000 peaked at 

70.1 between 1968 and 1972 and fell to 31.3 between 

1983 and 1987. Cerebrovascular disease death rates 

for American Indian women also peaked at 55.7 

between 1968 and 1972 and declined to a low of 19.3 

between 1983 and 1987. 

Asian Americans and Pacific Islanders 

From 1992 through 1994, the age-adjusted death 

rate per 100,000 population for cerebrovascular disease was 29.3 for Asian American and Pacific Islander 

men, 26.3 for white men, 22.4 for Asian American and 

Pacific Islander women, and 22.6 for white women 

(Table 2). 

In a study of stroke deaths occurring between 

1965 and 1972 among Japanese men living in Japan, 

Honolulu, and San Francisco, age-specific stroke death 

rates were highest among men living in Japan (Worth 

et al. 1975). Among men 60–64 years of age, annual 

death rates per 1,000 men were 5.4 in Japan, compared 

with 2.5 in San Francisco and 1.1 in Honolulu. For 

CHD, however, the death rates in Japan were lower 

than rates in Honolulu and San Francisco. Data from 

the Honolulu Heart Program suggest that other risk 

or protective factors associated with a Japanese diet, 

such as high alcohol intake and low intake of food from 

animal sources, may play important roles in the development of stroke and CHD in Honolulu and Japan, 

along with smoking, older age, high systolic blood 

pressure, and high serum cholesterol and glucose levels (Reed 1990). 

In a study of 1980 death rates among Asian 

Americans in Los Angeles, Frerichs and colleagues 

(1984) found that Koreans had the lowest age- and 

gender-adjusted death rate for cerebrovascular disease 

(48 per 100,000) and that Japanese had the highest rate 

(80 per 100,000). When the investigators compared the 

average age- and gender-adjusted death rates for these 

Asian Americans with rates for the entire county, 

the mortality ratio was 1.07 for Japanese and 0.65 for 

Koreans. 

Cigarette smoking was found to be an independent risk factor for stroke among men of Japanese 

ancestry who participated in the Honolulu Heart 

Program (Abbott et al. 1986). For all types of stroke, 

the estimated relative risk of smoking, adjusted for age 

and other major risk factors, was 2.5. This risk decreased to 1.5 among men who quit smoking during 

the six-year follow-up period and increased to 3.5 

among men who continued to smoke, indicating that 

cigarette smoking is a cause of stroke in Japanese men. 

Health Consequences 165 
 

Surgeon General's Report 

A subsequent analysis of participants in the Honolulu 

Heart Program indicated that cigarette smoking significantly increased the risk for thromboembolic stroke 

(Goldberg et al. 1995). 

Hispanics 

Studies about stroke among Hispanics have focused on the magnitude of this outcome in relation to 

other racial/ethnic groups. Between 1986 and 1988, 

the overall rate of death from cerebrovascular disease 

was lower among Hispanics than among whites in the 

United States (Desenclos and Hahn 1992). When cerebrovascular disease death rates for Hispanics and 

whites were compared, the mortality ratio for Hispanic 

men was 0.89, and the ratio for Hispanic women was 

0.84. Of the different Hispanic subgroups, Mexican 

Americans had the highest death rates from cerebrovascular disease. Sorlie and colleagues (1993) had 

similar observations when they estimated death rates 

using census data collected between 1973 and 1985. 

Age-adjusted death rate ratios for cerebrovascular disease were lower among Hispanics than among whites 

(0.60 for men and 0.76 for women). No details were 

provided for the different Hispanic subgroups. In 

more recent years, age-adjusted death rates for cerebrovascular disease were slightly lower among Hispanic men and women than among white men and 

women. For example, from 1992–1994, the ageadjusted death rate per 100,000 population for cerebrovascular disease was 22.7 for Hispanic men, 26.3 

for white men, 16.7 for Hispanic women, and 22.6 for 

white women (Table 2). 

Regional studies in California (Frerichs et al. 

1984), New Mexico (Kattapong and Becker 1993), and 

Texas (Stern and Gaskill 1978) provide further evidence 

that Hispanics have a lower risk of death from 

cerebrovascular disease than do whites and African 

Smoking and Pregnancy 

Americans. Frerichs and colleagues (1984) compared 

1980 death rates among the different racial/ethnic 

groups in Los Angeles County. The age- and genderadjusted cerebrovascular disease death rates per 

100,000 were 64 for Hispanics compared with 76 

for whites (death rate ratio, 0.84) and 94 for African 

Americans (death rate ratio, 0.68). 

After reviewing New Mexico vital statistics data 

for 1958–1987, Kattapong and Becker (1993) described 

time trends in deaths from cerebrovascular disease 

among Hispanics, whites, and American Indians. Except for the period 1983–1987, Hispanic men had lower 

death rates than white men. From 1983 to 1987, the 

ratio of death rates among Hispanic men (45.8 per 

100,000) compared with the rate among white men 

(36.1 per 100,000) was 1.27. For women, the pattern of 

death rates was less consistent. From 1958 through 

1972, Hispanic women had higher death rates than 

white women; between 1973 and 1982, they had lower 

rates; and from 1983 through 1987, Hispanic women 

had slightly higher death rates (43.1 per 100,000) than 

white women (39.3 per 100,000). 

Stern and Gaskill (1978) examined temporal 

trends in stroke deaths from 1970 through 1976 among 

Hispanics and whites living in Bexar County, Texas, 

which includes San Antonio. Stroke deaths were generally lower among Hispanic women, but no significant difference was observed between the rates among 

men of either racial/ethnic group. Furthermore, no 

temporal trends in stroke deaths were evident for 

either gender or racial/ethnic group. 

Cigarette smoking probably explains some of the 

risk of stroke among Hispanics. However, data to assess the strength of this relationship are not available. 

Because the data presented here suggest that stroke is 

a leading cause of morbidity and death among Hispanics (NCHS 1993), future studies should examine 

the specific role that cigarette smoking plays. 

Smoking has long been known to be associated 

with poor outcomes for the infants of mothers who 

smoke. Mean infant birth weight and low birth weight 

(LBW) (<2,500 grams or <5.5 pounds) are often studied as measures of fetal morbidity because birth weight 

is easy to measure. LBW can result either from preterm 

delivery (<37 weeks’ gestation) or from intrauterine 

growth retardation, but the distinction may be difficult to make. Smoking has been associated with an 

average decrease in birth weight of about 200 grams 

as well as LBW, preterm birth, perinatal mortality, and 

infant mortality (USDHHS 1980, 1989b; Malloy et al. 

1988; English and Eskenazi 1992). 

166 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Evidence that the relationship between smoking 

and poor infant outcomes is causal has been strengthened by recent studies that used biomarkers of tobacco 

exposure, such as saliva and serum cotinine (Bardy et 

al. 1993; Li et al. 1993; English et al. 1994). Bardy and 

colleagues (1993) demonstrated a dose-response relationship between serum cotinine and decreased gestational age, decreased birth weight, and decreased 

crown-heel length. 

The exact mechanisms whereby smoke exposure 

affects the fetus are poorly understood. Carbon monoxide, which impairs oxygen delivery to the fetus, and 

nicotine, which impairs placental blood flow, have 

been implicated as the causative substances in tobacco 

smoke (USDHHS 1980). 

The infant outcomes most often studied have 

been LBW and infant mortality. Sudden infant death 

syndrome (SIDS) is an important component of infant 

mortality because it is the most common cause of death 

among infants older than one month of age. Available 

data show that LBW, infant mortality, and SIDS occur 

differentially in different racial/ethnic groups in the 

United States (Table 10) (Kleinman 1990; NCHS 1994). 

In general, whites have lower rates of these conditions 

and other racial/ethnic groups tend to have higher 

rates, but considerable variation exists. 

Several studies have reported different effects 

of smoking on LBW, infant mortality, and SIDS 

across racial/ethnic minority groups. This section 

focuses only on those studies that have investigated 

potential racial/ethnic group differences in the relationship between smoking and infant outcomes. 

Studies of Low Birth Weight 

Nearly 25 years ago, the possibility was raised 

that smoking might have a differential effect on reproductive outcomes in different racial/ethnic groups 

(Lubs 1973). In a study of all singleton live births at 

Yale-New Haven Hospital in 1972, Lubs reported a difference in the effect of maternal smoking on LBW 

among 783 African American and 3,415 white women. 

A strong dose-response relationship was observed between the number of cigarettes smoked during pregnancy and infant LBW (defined as ≤2,500 grams for 

whites and ≤2,350 grams for African Americans). 

Among African American women, smoking 20 or more 

cigarettes per day was associated with a threefold increase in LBW, compared with only a twofold increase 

among white women. These racial/ethnic group differences were not explained by differences in age, 

prepregnancy weight, education, or marital status. 

Several more recent studies also provide evidence 

for the possibility of a differential effect of smoking 

on LBW among white and African American women. 

English and colleagues (1994) used interview data from 

the Child Health and Development Studies, conducted 

from 1959 through 1966 in California. Stored serum 

samples were analyzed for cotinine, and the levels 

were compared with self-reported cigarette consumption and infant birth weight for 374 African American 

and 829 white pregnant smokers separately. African 

American pregnant smokers were found to have 

higher serum cotinine levels than white pregnant 

smokers after the data were controlled for smoking 

dose and demographic confounders. No racial/ 

ethnic minority group difference was found in the 

rate of decrease in mean birth weight per given amount 

of cotinine in the serum of women who smoked. These 

data suggest that cigarette smoking may have a greater 

effect on birth weight among African Americans than 

among whites because higher cotinine levels are 

present in African American women than in white 

women who smoke the same amount; the higher 

cotinine levels may result from a greater intake of tobacco smoke per cigarette by African American women 

than by white women. 

Li and colleagues (1993) found a differential effect of smoking reduction during pregnancy on infant 

birth weights among African American and white 

women. Study subjects were 803 participants in an 

experimental trial of smoking cessation for pregnant 

women in Alabama; self-reported smoking was validated with saliva cotinine. Reduction was defined as 

a minimum drop in saliva cotinine values between the 

baseline (early pregnancy) visit and the late pregnancy 

visit. Smoking reduction increased the birth weight 

of infants of both African American and white women, 

but racial/ethnic group differences were present. 

Among white women, a reduction in smoking increased infant birth weight regardless of the baseline 

cotinine value. However, among African American 

women with high baseline cotinine values, a reduction in smoking had no effect on infant birth weights. 

The authors suggested that high levels of cigarette 

smoking (as detected by high cotinine levels) early 

in pregnancy may have irreversible effects on African 

American infants. 

Another recent study reported a differential effect of smoking on LBW (<2,500 grams) among multiparous African American and white women, but in the 

opposite direction (Neggers et al. 1994). Among African American women, the investigators found no significant difference in birth weight between smokers 

Health Consequences 167 
 

Surgeon General's Report 

Table 10. Rates of selected infant outcomes, by mother’s race/ethnicity,* United States 

Reference Outcome/years 

African

American 

American 

Indian and 

Alaska Native 

Asian American and Pacific Islander 

Total Chinese Japanese Filipino Other

 NCHS, public 

use data tapes,

 1992§ 

Low-birth-weight

 (<2,500 grams)

rate per 100 live 

births, 1992 13.4 6.2 6.6 5.2 7.5 7.4 6.9

 NCHS 

1994§ 

Infant mortality

rate per 1,000 

live births, 1987 17.8 13.0 7.3 6.2 6.6 6.6 7.9

 Kleinman 1990 Sudden infant 

death syndrome 

rate per 1,000 

live births, 

1983–1984 2.41 3.44 0.95 NA NA NA NA 

*The categories African American and white include persons of Hispanic and non-Hispanic origin. Conversely, 

persons of Hispanic origin may be included in other categories as well. 

†

Reported for selected states only; reporting areas for Hispanic origin vary by year. 

and nonsmokers, whereas among white women, the 

infants of smokers weighed significantly less than 

those of nonsmokers. However, no information was 

available on the number or type of cigarettes smoked 

or the biomarker of exposure; these results were adjusted only for the mother’s parity, age, height, and 

alcohol consumption as well as the infant’s gender and 

gestational age at birth. In addition, the study was 

not designed to study the relationship between smoking and LBW but to determine whether the relationship between maternal triceps skinfold thickness and 

infant birth weight was modified by smoking and 

race/ethnicity. 

Two studies have reported that smoking is related to an elevated risk of LBW among both African 

American and white women, but neither study found 

significant racial/ethnic group differences. In a population-based, case-control study of African American 

and white women delivering singleton infants without congenital anomalies in a large urban county of 

California, the Alameda County Low Birth Weight 

Study Group (1990) found that the risk of LBW associated with regular smoking throughout pregnancy was 

3.0 (95 percent confidence interval [CI], 1.7–5.3) 

for white women and 3.6 (95 percent CI, 2.4–5.6) for 

African American women (adjusted for age, parity, 

prepregnancy weight, socioeconomic status, alcohol 

use, prior LBW birth, and prenatal care). Unfortunately, the authors were unable to adjust the data for 

the number of cigarettes smoked. 

Castro and colleagues (1993) reported a study of 

maternal smoking and substance abuse during pregnancy and found similar associations between smoking during pregnancy and small size for gestational 

age (birth weight of less than the 10th percentile for 

gestational age) for African American and white 

women (odds ratio [OR] for African American women, 

2.0 [95 percent CI, 1.3–3.1]; OR for white women, 

2.4 [95 percent CI, 1.7–3.0]). These results were 

adjusted for maternal age, parity, marital status, insurance status, alcohol use, marijuana use, and other 

drug use; however, no information was available on 

the number of cigarettes smoked or the biomarker of 

exposure. 

Few studies have examined the relationship between smoking and LBW among Hispanic populations. Cohen and colleagues (1993) analyzed birth 

weight data on 19,571 Hispanic infants and 206,973 

white infants (those whose mothers did not indicate 

they were of Hispanic origin) born in Massachusetts 

168 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Hispanic† 

Mexican Central and 

Total American Puerto Rican Cuban South American Other‡ White 

6.4 6.0 8.8 6.0 5.6 7.5 5.9 

8.2 8.0 9.9 7.1 7.8 8.7 8.2 

NA 0.84 1.38 0.83 0.53 1.52 1.21 

‡

Includes persons of unknown Hispanic origin.
 

§

Data calculated to one significant digit.
 

NA = data not available.
 

between 1987 and 1989 and found that the incidence 

of LBW ranged from a high of 73 per 1,000 Puerto Rican 

infants to a low of 32.2 per 1,000 Cuban infants. The 

crude percentage of LBW was higher for smokers than 

for nonsmokers in each racial/ethnic group; however, 

multivariate adjusted risks were not presented for 

racial/ethnic groups separately. 

Several studies have demonstrated associations 

between smoking and LBW in specific racial/ethnic 

minority groups, including Puerto Ricans (Becerra and 

Smith 1988), Mexican Americans (Wolff et al. 1993), 

North American Indians (Godel et al. 1992), and African Americans (Jacobson et al. 1994; Johnson et al. 

1994). In each instance, smoking was shown to be related to lower birth weight; however, these studies did 

not provide data on other racial/ethnic groups, which 

might have allowed comparisons. 

The percentage of LBW (<2,500 grams) in 

the United States in 1993 was higher overall for smokers (11.8 percent) than for nonsmokers (6.6 percent) 

(NCHS 1996b). Although a higher percentage of white 

mothers (16.8) smoked during pregnancy than did 

African American mothers (12.7), African American 

women had a higher percentage (13.3) of LBW live 

births than white women (6.0) did in 1993. Age- and 

racial/ethnic-specific analyses of population data may 

be more revealing. Land and Stockbauer (1993), for 

example, found that the teenage-specific LBW rate 

for African Americans in Missouri dropped by 13.6 

percent from 1978–1990, concomitant with a drop in 

cigarette smoking prevalence among young African 

American mothers. Analyses of individual data statistically controlled for confounding factors such as 

preterm deliveries and maternal parity, weight, and 

access to health care (USDHHS 1989a) would be preferable. The studies of individuals that are reported in 

this section provide more useful data than do population-based ecological comparisons on the relationship 

between cigarette smoking and the increased occurrence of LBW in various racial/ethnic groups. 

Studies of Infant Mortality and Sudden 

Infant Death Syndrome 

Only one study has examined the risks of smoking associated with overall fetal and infant mortality 

in specific racial/ethnic groups (Kleinman et al. 1988). 

The authors used data from Missouri live birth, fetal 

death, and infant death certificates for births during 

Health Consequences 169 
 

Surgeon General's Report 

Table 11.	 Risk of sudden infant death syndrome associated with smoking, by race/ethnicity, selected 

studies, United States 

African American 

American Indian 

and Alaska Native 

Asian American 

and Pacific Islander 

Reference Exposure/years OR* CI† OR CI OR CI

 Li and Daling 

 1991‡ 

Active smoking

1984–1989 3.1 1.7–5.9 1.4 0.9–2.4 2.7 1.1–6.6

 Schoendorf 

 and Kiely 

 1992§ 

Passive exposure

1988 1.8 1.0–3.0 NA NA NA NA

Combined exposure 

1988 3.1 2.3–4.2 NA NA NA NA

 Klonoff-Cohen 

 et al.Δ 1995 

Passive exposure

1989–1992 5.0 1.1–22.8 NA NA NA NA 

*OR = odds ratio. 

†

CI = 95% confidence interval. 

‡

Li and Daling assessed the risk, by mother’s ethnicity, associated with active maternal smoking during 

pregnancy; ORs are adjusted for maternal age, marital status, prenatal care, parity, and birth weight. 

§

Schoendorf and Kiely assessed the risk, by mother’s ethnicity, associated with (1) passive smoking (maternal 

smoking after birth but not during pregnancy) and (2) combined exposure (maternal smoking during 

pregnancy and after birth); ORs are adjusted for maternal age, education, and marital status. 

Δ Klonoff-Cohen et al. assessed the risk, by infant’s ethnicity, associated with total passive smoke exposure from 

all adults (mother, father, live-in adults, and day-care providers); ORs are adjusted for birth weight, routine 

sleep position, medical conditions at birth, breast-feeding, prenatal care, and maternal smoking during 

pregnancy. 

NA = data not available. 

1979–1983 to examine the risk of mortality associated 

with smoking during pregnancy. They found no significant variation in the effects of smoking on African 

American and white women, with adjusted ORs ranging from 1.3 to 1.6, depending on parity and the 

amount smoked. 

11). The ORs were not significantly different between 

groups, except between African Americans and American Indians. No information was available on the number of cigarettes smoked or the biomarker of exposure. 

Schoendorf and Kiely (1992) used data from the 

1988 National Maternal and Infant Health Survey to 

study the association between SIDS and maternal 

smoking (either passive [only after birth] or combined 

[during pregnancy and after birth]) among infants of 

normal birth weight. They found similar increased 

risks of SIDS among African American and white infants exposed to maternal smoking (Table 11), after 

adjusting the data for maternal age, education, and 

marital status. Although white mothers reported 

heavier smoking than African American mothers, the 

authors did not adjust their findings for the number 

of cigarettes smoked. 

Three studies have examined the effects of smoking on SIDS in specific racial/ethnic minority groups 

(Table 11) (Li and Daling 1991; Schoendorf and Kiely 

1992; Klonoff-Cohen et al. 1995). Li and Daling (1991) 

used data from Washington State birth records from 

1984 through 1989, linked with infant death records. 

After adjusting the data for maternal age, marital status, prenatal care, parity, and birth weight, they found 

a statistically significant increased risk of SIDS associated with maternal smoking during pregnancy in all 

racial/ethnic groups except American Indians (Table 

170 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Hispanic White
 

OR CI OR CI
 

5.5 1.4–22.0 2.2 1.8–2.6 

NA NA 3.1 2.3–4.2
 

NA NA 1.8 1.0–3.0
 

2.6 0.9–7.3 3.4 1.6–7.2 

Klonoff-Cohen and colleagues (1995) conducted 

a 1989–1992 case-control study of passive smoking and 

SIDS in five counties in southern California. The OR 

for SIDS associated with all types of passive smoke 

exposure combined was 3.50 (95 percent CI, 1.81–6.75), 

after adjustment for birth weight, routine sleep position, medical conditions at birth, breast-feeding, prenatal care, and maternal smoking during pregnancy. 

The evidence suggested a dose-response relationship, 

with an increased risk of SIDS associated with increased passive exposure to smoke. The authors also 

stratified the data by racial/ethnic group and found 

similar effects across groups (Table 11), although the 

results were not adjusted for the number of cigarettes 

smoked. 

Health Problems Affecting 

Pregnant Women 

Smoking is related to a variety of health problems affecting pregnant women, ranging from ectopic 

pregnancy to abruptio placentae (USDHHS 1980; 

Rosenberg 1987), but race- and ethnic-specific data are 

not generally available. In addition to exploring 

smoking’s effects on fetuses and infants, future research should focus on the race- and ethnic-specific 

effects of smoking on the pregnant woman herself. 

Implications 

The question of whether race- and ethnic-specific 

differences exist in the relationship between smoking 

and infant outcomes has not been satisfactorily 

resolved. Many intriguing questions have been raised, 

but investigators have not yet determined the exact 

nature of such differences or what factors mediate 

them. 

Comparative studies have been hampered by 

inconsistent and inadequate measurement of exposure. 

For example, few investigators have fully explored issues of dose of smoking such as the number of cigarettes smoked or the levels of biomarkers, although 

the amount of smoking during pregnancy does differ 

among racial/ethnic minority groups (see Chapter 2). 

Moreover, even though the timing of smoking during 

pregnancy may play a critical role in the development 

of LBW (Lieberman et al. 1994), few studies of LBW 

have separately assessed the effects of smoking during each trimester of pregnancy. Patterns of quitting 

and reducing smoking during pregnancy may in fact 

differ by race/ethnicity. 

Racial/ethnic group differences in nicotine metabolism may also be important (Wagenknecht et al. 

1990; English et al. 1994). African American pregnant 

smokers appear to have higher serum cotinine levels 

than white pregnant smokers when the data are controlled for nicotine dose (English et al. 1994). Thus, 

fetal exposure may be higher among African Americans than among whites for a given number of cigarettes smoked. 

Racial/ethnic group differences in oxygencarrying capacity may also play a role in mediating the 

effects of smoking. In 1973, Lubs suggested that the 

increased effects of smoking on birth weight among African American women might in part be explained by 

higher rates of sickle cell trait or glucose-6-phosphate 

dehydrogenase (G6PD) deficiency, which impair oxygen-carrying capacity (Lubs 1973). No published reports have examined Lubs’s hypothesis. In addition, 

anemia, which is more prevalent among African American women, may be a risk factor for preterm delivery 

(Hogue and Yip 1989). 

Future studies of smoking and pregnancy 

outcomes should consider racial/ethnic group differences in the timing of smoking during pregnancy, 

nicotine metabolism, and factors that affect oxygencarrying capacity, such as sickle cell trait, G6PD deficiency, and anemia. 

Health Consequences 171 
 

Surgeon General's Report 

Summary of Health Consequences from Active Cigarette Smoking 

Attempts to predict racial- and ethnic-specific 

rates of disease incidence and mortality from racial- and 

ethnic-specific cigarette smoking prevalences are of 

limited value, because other factors can also influence 

disease rates. When studies of individuals are conducted, the data lead to the conclusion that cigarette 

smoking is a major cause of disease and death in each 

of the four U.S. racial/ethnic minority groups studied 

in this report. These studies reveal few major differences in the risk ratios for various diseases. Limited 

epidemiological and biological data suggest that African Americans may be at an especially high level of 

risk for lung cancer. Although further research could 

clarify the nature of the interrelationships between 

cigarette smoking, other risk factors, potential modifying factors, racial/ethnic group membership, and 

various disease outcomes, it is clear that reducing tobacco use in each of the nation’s racial/ethnic groups 

will reduce the incidence and mortality from several 

of the nation’s leading causes of death and is a major 

public health goal to pursue. 

Effects of Exposure to Environmental Tobacco Smoke
 

Environmental tobacco smoke (ETS) is the mixture of sidestream smoke and exhaled mainstream 

smoke that is produced by active smokers and then 

involuntarily inhaled by nonsmokers. Over the past 

decade, the adverse effects of ETS have been reported 

in the literature. The 1986 Surgeon General’s report 

on smoking and health (USDHHS 1986a) concluded 

that the inhalation of ETS (labeled “involuntary smoking” in that report) is a cause of diseases, including 

lung cancer, in healthy nonsmokers and that the children of parents who smoke are more likely than the 

children of nonsmoking parents to have respiratory 

infections, respiratory symptoms, and abnormal maturation of lung function. Similar conclusions were also 

reached in 1986 by a committee of the National Research Council (1986). More recently, the U.S. Environmental Protection Agency (1992) assessed the risks 

associated with ETS, and the results reaffirmed that 

ETS is carcinogenic and that it exacerbates and may 

even cause childhood asthma. To date, racial/ethnic 

group differences in the adverse effects of ETS have not 

been investigated, although a number of studies have 

investigated racial/ethnic group differences in the level 

of exposure to ETS and in people’s reactions to ETS. 

Overpeck and Moss (1991) examined patterns of 

exposure to ETS among children five years of age and 

younger included in the 1988 NHIS and found that 

exposure varied by race/ethnicity and socioeconomic 

status (Table 12). African American children were the 

most likely to be exposed to ETS, whereas Hispanic 

children were the least likely to be exposed to ETS. 

Moreover, in the CARDIA (Coronary Artery Risk Development in [Young] Adults) study, the prevalence 

of exposure to ETS was significantly higher among 

African Americans (32 percent) than among whites (24 

percent) (Wagenknecht et al. 1993). Overall, 28 percent of individuals 18–30 years of age were exposed 

to ETS, as detected by a serum cotinine level of 2–13 

ng/mL. Adult survey data from the 1992 California 

Tobacco Survey show that Hispanics (21.3 percent) 

were most likely to report working around a cigarette 

smoker within the two weeks before the survey (Pierce 

et al. 1994). Asian Americans (13.2 percent) and African Americans (12.8 percent) reported being exposed 

to ETS at work in lower proportions than whites 

(17.9 percent). Data from the 1988 NHIS (CDC 1992) 

show that 40.3 percent of employed adults reported 

that cigarette smoking was allowed in their place of 

employment. The percentages of persons who 

reported experiencing discomfort caused by ETS exposure at work did not differ significantly by racial/ 

ethnic group. In a 1992–1993 study of U.S. adults who 

worked indoors, Asian Americans and Pacific Islanders (51.4 percent) were the most likely and African 

Americans (43.3 percent) were the least likely to work 

under a completely smoke-free ETS policy (Gerlach et 

al. 1997). Since most studies suggest that differences 

exist in the ETS exposure of various racial/ethnic 

groups, studies to monitor the health effects of this 

exposure are needed. 

172 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 12.	 Exposure to household smoke among children 5 years of age and younger and percentage 

distribution, by level of exposure since birth and selected characteristics, United States, 1988 

Percentage distribution* 

Exposed since birth 

Number of Current Former 

Characteristic 

children 

(in thousands)† Total 

Not exposed 

since birth Total‡ 

smoker in 

household 

smoker in 

household 

All children§ 19,019 100.0 51.1 (0.9) 48.9 (0.9) 42.4 (0.9) 6.1 (0.4) 

Ethnicity 

African American 2,759 100.0 41.5 (2.4) 58.5 (2.4) 51.3 (2.4) 6.7 (1.2) 

White 15,575 100.0 51.9 (1.0) 48.1 (1.0) 41.6 (1.0) 6.1 (0.4) 

Hispanic origin 

Non-Hispanic 16,923 100.0 50.4 (1.0) 49.6 (1.0) 43.2 (1.0) 6.0 (0.4) 

Hispanic 2,096 100.0 56.4 (2.6) 43.6 (2.6) 35.8 (2.5) 6.9 (1.2) 

Mexican American 1,006 100.0 60.7 (4.1) 39.3 (4.1) 31.8 (3.8) 6.5 (1.5) 

Annual household income 

<$10,000 2,685 100.0 33.4 (2.1) 66.6 (2.1) 57.7 (2.3) 8.7 (1.1) 

$10,000–$24,999 5,436 100.0 44.3 (1.5) 55.7 (1.5) 48.8 (1.6) 6.3 (0.7) 

$25,000–$39,999 4,871 100.0 55.9 (1.7) 44.1 (1.7) 38.3 (1.6) 5.4 (0.7) 

≥$40,000 4,149 100.0 65.7 (1.8) 34.3 (1.8) 29.5 (1.5) 4.6 (0.9) 

Poverty statusΔ 

In poverty 3,376 100.0 36.4 (2.1) 63.6 (2.1) 55.7 (2.3) 7.6 (1.0) 

Not in poverty 14,582 100.0 54.8 (1.0) 45.2 (1.0) 39.2 (1.0) 5.6 (0.4) 

Mother’s education 

<12 years 3,279 100.0 33.3 (2.2) 66.7 (2.2) 61.2 (2.1) 5.1 (0.8) 

12 years 8,014 100.0 44.5 (1.4) 55.5 (1.4) 47.9 (1.4) 7.3 (0.6) 

>12 years 7,505 100.0 66.3 (1.2) 33.7 (1.2) 27.6 (1.1) 5.4 (0.6) 

Place of residence 

Metropolitan statistical area 14,550 100.0 51.5 (1.0) 48.5 (1.0) 42.2 (1.1) 5.9 (0.4) 

Central city 5,994 100.0 49.4 (1.4) 50.6 (1.4) 43.6 (1.5) 6.3 (0.6) 

Not central city 8,556 100.0 52.9 (1.4) 47.1 (1.4) 41.1 (1.4) 5.6 (0.6) 

Not metropolitan statistical area 4,469 100.0 49.7 (1.9) 50.3 (1.9) 43.1 (1.7) 6.8 (0.8) 

*Figures in parentheses are standard errors of estimates. 

†

Excludes children whose exposure status is unknown. 

‡

Includes children exposed since birth whose period of exposure is unknown. 

§

Includes all other ethnicities, unknown household income, unknown poverty status, unknown education of mother, 

and unknown assessed health status. 

Δ

Poverty status determined in the National Health Interview Survey by family size, number of children, and 

household income by using 1987 poverty levels defined by the U.S. Bureau of the Census. 

Source: Adapted from Overpeck and Moss 1991. 

Health Consequences 173 
 

Surgeon General's Report 

Effects of Smokeless Tobacco Use 

Smokeless tobacco refers to moist oral snuff, dry 

oral and nasal snuff, and chewing tobacco. Smokeless 

tobacco is commonly used by youths, particularly 

those in rural areas, and it is highly addictive 

(USDHHS 1986b; Boyd and Glover 1989). Among the 

adverse health effects of smokeless tobacco use are oral 

cancer, oral leukoplakia (white mouth lesions that may 

be precancerous), gingival recession, periodontal diseases, elevated blood pressure, and increased risk for 

cardiovascular disease (NCI 1992; USDHHS 1994; 

Bolinder et al. 1994). 

Few studies have examined the adverse health 

effects of smokeless tobacco use in racial/ethnic 

minority populations, and the research that has been 

conducted has been limited in several ways: (1) population-based, case-control studies rarely have sufficient 

numbers of racial/ethnic group members to allow 

group-specific analyses for groups other than African 

Americans (Blot et al. 1988; Day et al. 1993); (2) because the use of smokeless tobacco and associated 

health effects are relatively rare in most racial/ethnic 

groups, the feasibility of conducting prospective investigations is limited; and (3) smokeless tobacco users often report current or past use of other substances, 

such as cigarettes and alcohol, that are risk factors for 

health effects also associated with smokeless tobacco 

use, such as oral cancer (Blot et al. 1988; Mattson and 

Winn 1989). These multiple risk factors complicate or 

preclude analysis of the independent effects of smokeless tobacco use. 

The valid data that are available, however, indicate that for men, the prevalence of smokeless tobacco 

use is highest among American Indians, Alaska 

Natives, and whites; for women, the prevalence is 

highest among American Indians, Alaska Natives, and 

African Americans (CDC 1993c). Data for 1989–1991 

show that rates of death from cancers of the lip, oral 

cavity, and pharynx have been higher among African 

American men (7.8 per 100,000) than among Puerto 

Rican men (3.9 per 100,000), Asian American and Pacific Islander men (3.4 per 100,000), and white men (3.2 

per 100,000) (Table 2) (NCHS, public use data tapes, 

1989–1991; U.S. Bureau of the Census 1993). 

In a case-control study, Winn and colleagues 

(1981) examined the estimated relative risk of oral and 

pharyngeal cancer associated with snuff-dipping 

among African American and white women in the 

southern United States. Although the relative risk was 

higher among white women (4.2) than among African 

American women (1.5), white women had dipped 

snuff for significantly longer periods and had consumed more snuff per week than African American 

women had. The relative risk for cancers of the gum 

and buccal mucosa increased with longer duration of 

snuff use, but this analysis was not conducted separately for African Americans and for whites. 

A few studies of the health effects associated with 

smokeless tobacco use have been conducted among 

American Indian and Alaska Native populations. In a 

study of Navajo youths aged 14–19 years in New 

Mexico (Wolfe and Carlos 1987), 64 percent of the teenagers used smokeless tobacco products. Oral leukoplakia was found in 26 percent of smokeless tobacco 

users, representing a ninefold increase in risk when 

these youths were compared with those who did not 

use smokeless tobacco. The estimated relative risk of 

leukoplakia increased with duration and frequency of 

smokeless tobacco use. The investigators observed no 

apparent differences between users and nonusers of 

smokeless tobacco regarding gingival bleeding, calculus accumulation, or the extent or severity of gingival 

recession or loss of periodontal attachment. 

In a survey of students in grades 7–12 attending 

schools on the Rosebud Sioux Reservation in South 

Dakota, more than one-third of the students reported 

regularly using smokeless tobacco (CDC 1988). Of 

these regular users, 37 percent had oral lesions (i.e., 

any white or red wrinkled area in the mouth or buccal 

mucosa). The students with oral lesions had used 

smokeless tobacco for a mean of 3.4 years, 6.6 times 

per day, and they had held each dip or chew for an 

average of 40 minutes. Students who used smokeless 

tobacco but did not have lesions had used the product 

for a mean of 2.5 years, 2.9 times per day, and they 

had held each dip or chew for an average of 30 minutes. This suggests a possible relationship between 

duration and intensity of smokeless tobacco use and 

the occurrence of oral lesions. The prevalence of oral 

lesions among nonusers of smokeless tobacco was not 

reported. 

The 1986–1987 National Survey of Oral Health 

in U.S. School Children conducted oral clinical examinations on 17,027 children aged 12–17 years who 

provided information on their use of various tobacco 

products (Tomar et al. 1997). Smokeless tobacco 

lesions (defined by the authors as slight to heavy 

174 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

wrinkling of the oral mucosa) were more common chewing tobacco use. Lesions were more common 

among white (2.0 percent) than among African Ameri- with increasing duration and frequency of smokeless 

can (0.2 percent) or Hispanic (0.8 percent) school chil- tobacco use. Because of small sample sizes, analyses 

dren. In white males, the strongest correlates of le- were not conducted on data for other racial/ethnic 

sions were, in order, current snuff use and current groups. 

Nicotine Addiction and Racial/Ethnic Differences 

Most smokers have difficulty quitting because 

they are addicted to nicotine (USDHHS 1988). An understanding of the role of nicotine addiction in determining smoking behavior could help clarify racial/ 

ethnic differences in tobacco use and facilitate smoking cessation treatment. Nicotine addiction was 

reviewed extensively in the 1988 Surgeon General’s 

report on smoking and health (USDHHS 1988). Concepts of addiction also have been reviewed in subsequent Surgeon General’s reports (USDHHS 1989b, 

1994). However, relatively little research has been conducted on racial/ethnic minority differences in nicotine addiction. This section provides a brief review of 

nicotine addiction and discusses the limited data on 

racial/ethnic differences and nicotine addiction. 

Nature of Addiction 

In the broadest sense, addiction (often used interchangeably with dependence) indicates a loss of 

control over drug-taking behavior. The World Health 

Organization describes drug dependence as “a behavioral pattern in which the use of a given psychoactive 

drug is given a sharply higher priority over other behaviors which once had a significantly higher value” 

(Edwards et al. 1982). In other words, drug use controls one’s behavior to an extent considered detrimental to the individual or to society. 

The criteria for drug dependence, described in 

the 1988 Surgeon General’s report on smoking and 

health (Table 13) (USDHHS 1988), include highly controlled or compulsive use of a drug, the use of a drug 

that produces psychoactive effects, and evidence that 

drug-taking behavior is reinforced by the effects of the 

drug. Other criteria for drug dependence have been 

developed by the American Psychiatric Association 

[APA] (1994) for the fourth edition of the Diagnostic 

and Statistical Manual of Mental Disorders (DSM-IVTM) 

(Table 14). These criteria are quite specific and useful 

in diagnosing drug dependence in individual patients. 

Pharmacologic Factors in Nicotine Addiction 

Nicotine addiction, like all drug addictions, is a 

complex process involving the interplay of pharmacology, learned or conditioned factors, personality, 

social setting, and genetics (USDHHS 1988, 1994; 

Benowitz 1992a). The pharmacologic reasons for drug 

use include an enhancement of one’s mood or functioning. Drugs produce such effects either directly or 

by relieving withdrawal symptoms. The pharmacologic factors involved in nicotine addiction work in 

several ways. For example, positive effects reported 

after smoking tobacco include pleasure, arousal, and 

relaxation as well as improved attention, reaction time, 

and performance of certain tasks. In addition, cigarette smoking has been cited as effective in relieving 

aversive emotional states, including reducing anxiety 

or stress, relieving hunger and preventing weight gain, 

and relieving nicotine withdrawal symptoms (Table 

15) (Benowitz 1992a). 

The pharmacology of nicotine addiction can be 

discussed in relation to several processes: (1) absorption, distribution, and elimination of nicotine in the 

body (pharmacokinetics); (2) pharmacologic effects of 

nicotine on target organs (pharmacodynamics); and 

(3) translation of pharmacologic effects into behavior. 

These processes are reviewed in the following sections, 

and racial/ethnic differences are discussed when 

information is available. 

Absorption, Distribution, and Elimination of 

Nicotine in the Body 

Nicotine from tobacco smoke is absorbed rapidly 

across the lungs’ alveolar membranes and into the systemic circulation (Benowitz 1990). Following absorption from the lung, concentrations of nicotine in 

the blood rise quickly and peak at the completion of 

smoking. Concentrations of nicotine in arterial blood 

leaving the lungs and heart are several times higher 

than those measured in venous blood (Henningfield 

Health Consequences 175 
 

 

Surgeon General's Report 

Table 13. Criteria for drug dependence 

Primary criteria 

Highly controlled or compulsive use
 

Psychoactive effects
 

Drug-reinforced behavior
 

Additional criteria 

Addictive behavior often involves—
 

stereotypic patterns of use
 

use despite harmful effects
 

relapse following abstinence
 

recurrent drug cravings
 

Dependence-producing drugs often produce— 

tolerance 

physical dependence 

pleasant (euphoric) effects 

Source: Adapted from U.S. Department of Health 

and Human Services 1988. 

et al. 1993). Within 10 to 19 seconds after the start of a 

puff, nicotine is delivered to the brain. Rapid delivery 

of high concentrations of nicotine to the brain provides 

the possibility for rapid behavioral reinforcement from 

smoking and allows the smoker to control the concentration of nicotine in the brain and, hence, to modulate the pharmacologic effects of nicotine. 

In contrast, the absorption of nicotine from 

smokeless tobacco is gradual, with blood levels peaking at the end of chewing tobacco or using snuff 

(Benowitz et al. 1988). Buccal-oral absorption results 

in a gradual increase in concentrations of nicotine in 

the brain, with relatively little arterial-venous disequilibrium. This pattern of absorption may provide a less 

intense pharmacologic reinforcement than that produced by smoke inhalation but is sufficient to produce 

addiction. 

The level of nicotine in the body is determined 

by the balance of nicotine intake from tobacco and the 

rate of nicotine elimination from the body. Nicotine is 

eliminated primarily by hepatic metabolism, with a 

small amount (5–10 percent) excreted unchanged in 

the urine. The primary metabolite of nicotine is 

cotinine, which has been used as a measure of nicotine 

exposure (Benowitz 1996). Keenan and colleagues 

(1994, 1995) recently published preliminary data 

consistent with the hypothesis that cotinine has some 

psychoactive properties. These effects do not appear 

to be mediated by nicotine receptor agonism, but could 

play some role in nicotine addiction. The rate of metabolizing nicotine varies considerably from person to 

person (Benowitz et al. 1982). A person who metabolizes nicotine slowly would not need to take in as much 

nicotine to achieve a particular level of nicotine in the 

body as a person who metabolizes nicotine more rapidly. The level of nicotine in the body appears to be 

positively correlated with the degree of nicotine dependence and negatively correlated with the likelihood 

of successful cessation therapy (USDHHS 1988; 

Pomerleau et al. 1990; Sutherland et al. 1992). 

Theoretically, racial/ethnic differences in the absorption, distribution, or elimination of nicotine could 

influence the likelihood of developing nicotine dependence (see Racial/Ethnic Differences in Nicotine Metabolites later in this chapter for further discussion 

of this topic). 

Pharmacodynamics of Nicotine 

Nicotine acts on nicotinic cholinergic receptors 

in the brain and other organs of the body, enhancing 

the release of neurotransmitters such as acetylcholine, 

norepinephrine, dopamine, beta-endorphin, and serotonin (USDHHS 1988). The physiologic consequences 

of nicotine intake include behavioral arousal and sympathetic neural activation (Table 15) (Benowitz 1992a). 

The release of specific neurotransmitters has been 

speculatively linked to the various reinforcing effects 

of nicotine (Pomerleau and Pomerleau 1984). For example, the enhanced release of dopamine and norepinephrine may be associated with pleasure as well as 

appetite suppression, the latter of which may contribute to lower body weight. The release of acetylcholine may be associated with improved performance of 

behavioral tasks and improved memory, whereas the 

release of beta-endorphin may be associated with reduced anxiety and tension. 

Although smokers give different explanations for 

smoking, most agree that smoking produces arousal, 

particularly with the first few cigarettes of the day, and 

paradoxically, smoking can also be calming or relaxing, especially in stressful situations (Pomerleau and 

Pomerleau 1984; Benowitz 1992a). Consistent with 

reports of arousal, the smoking of cigarettes or 

the administration of nicotine is followed by 

electroencephalographic desynchronization, with an 

upward shift in the brain’s dominant alpha frequency 

and decreased total alpha and theta power (Pickworth 

et al. 1989). 

176 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 14. American Psychiatric Association diagnostic criteria for substance dependence 

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested

 by three or more of the following consequences, occurring at any time in the same 12-month period:

 Tolerance, as defined by either— 

need for markedly increased amounts of the substance to achieve intoxication or desired effect or 

markedly diminished effect with continued use of the same amount of the substance.

 Withdrawal, as manifested by either— 

the characteristic withdrawal syndrome* for the substance or 

the same (or a closely related) substance being taken to relieve or avoid withdrawal symptoms.

 Consumption of the substance in larger amounts or over a longer period than was intended.

 Having a persistent desire to cut down or control substance use or unsuccessfully trying to do so.

 Spending a great deal of time in activities necessary to obtain the substance (e.g., visiting multiple doctors or

 driving long distances), use the substance (e.g., chain-smoking), or recover from its effects.

 Giving up or reducing important social, occupational, or recreational activities because of substance use.

Continuing to use the substance, despite the knowledge that one has a persistent or recurrent physical or

psychological problem likely caused or exacerbated by the substance (e.g., current cocaine use despite

recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was

worsened by alcohol consumption). 

*The characteristic withdrawal syndrome for nicotine refers to the daily use of nicotine for at least several 

weeks and abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 

hours by four or more of the following signs: dysphoric or depressed mood; insomnia; irritability, frustration, 

or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; increased appetite or weight gain. 

Source: Adapted from American Psychiatric Association 1994. 

Several researchers have studied the effects of 

cigarette smoking and nicotine administration on the 

behavior of smokers who have abstained from tobacco 

use (abstinent smokers) (USDHHS 1988; Hughes et al. 

1990; Warburton 1990; Le Houezec and Benowitz 1991; 

Heishman et al. 1994). Many of these studies have 

shown that nicotine restores tobacco-abstinencerelated deficits in attention and short-term memory 

and decreases reaction time (Peeke and Peeke 1984; 

USDHHS 1988; Snyder et al. 1989; Snyder and 

Henningfield 1989; Warburton 1990; Levin 1992; 

Pritchard et al. 1992). Nicotine also may increase a 

person’s vigilance in performing repetitive tasks and 

increase selective attention in abstinent smokers. The 

effects of nicotine on the cognitive functioning of nonsmokers have not been clearly identified (USDHHS 

1988; Heishman et al. 1994). Smokers commonly report pleasure, mental stimulation, and reduction of 

stress after smoking a cigarette (McKennell 1970; 

Russell et al. 1974). 

Cigarette smoking and nicotine also have sympathomimetic action, producing brief increases in 

blood pressure, heart rate, and cardiac output with 

cutaneous vasoconstriction (Benowitz 1988). Nicotine 

causes muscle relaxation by stimulating discharge of 

the Renshaw cells and pulmonary afferent nerves, 

which inhibit motor neuron activity and relax certain 

muscles. However, not all muscles are relaxed; 

increased electromyographic activity and tonicity 

of the large upper-back muscles (trapezius) have been 

observed after smoking (Fagerström and Götestam 

1977). 

Health Consequences 177 
 

 

Surgeon General's Report 

Table 15. Human pharmacology of nicotine 

Primary effects*	 Withdrawal symptoms 

Pleasure	 Irritability, restlessness 

Arousal, enhanced vigilance	 Drowsiness 

Improved task performance	 Difficulty concentrating, impaired task performance 

Relief of anxiety	 Anxiety 

Reduced hunger	 Hunger 

Body weight reduction	 Weight gain 

Sleep disturbance 

Cravings or strong urges for nicotine 

Electroencephalogram desynchronization 

Increased circulating levels of catecholamines, Decreased catecholamine excretion† 

vasopressin, growth hormone, adrenocorticotropic hormone (ACTH), cortisol, 

prolactin, beta-endorphin 

Increased metabolic rate 

Lipolysis, increased free fatty acids 

Heart rate acceleration Heart rate slowing† 

Cutaneous and coronary vasoconstriction 

Increased cardiac output 

Increased blood pressure 

Skeletal muscle relaxation 

*Some of these effects are related in part to relief of withdrawal symptoms. 

†

May represent a return to baseline rather than true withdrawal. 

Source: Benowitz 1992a. 

Genetic differences in the number of nicotinic 

receptors and pharmacologic responses to nicotine 

have been well demonstrated in animals (Marks et al. 

1991). Genetic differences in pharmacologic responses 

to nicotine could underlie different susceptibilities to 

nicotine addiction, as appears to be the case for certain types of alcohol addiction (Hughes 1986; 

Cloninger 1987; Carmelli et al. 1992). Genetic susceptibility may vary by ancestry of origin (for example, 

sickle cell disease and African American ancestry). 

Genetic differences in nicotine responsiveness associated with ancestry of origin remain to be explored. 

Tolerance, Withdrawal, and Addictive Tobacco Use 

With prolonged or repeated exposure to nicotine, 

neurologic changes (neuroadaptation) occur. In animals, chronic nicotine exposure results in an increased 

number of nicotinic receptors in the brain (Marks et 

al. 1985). During the course of these changes, the 

smoker develops more brain nicotinic receptors and 

an increased tolerance to the various effects of nicotine. For example, previous studies have shown that 

at autopsy, the number of nicotinic receptors was 

greater in the brains of cigarette smokers than in those 

of nonsmokers (Benwell et al. 1988). Smokers develop 

substantial tolerance to the behavioral arousal and 

cardiovascular effects of nicotine in the course of a 

single day (Benowitz et al. 1989b). They can regain 

sensitivity to the effects of nicotine, at least in part, 

after overnight abstinence from smoking. 

As a consequence of these neurologic changes, 

nicotine withdrawal symptoms appear when nicotine 

use is abruptly stopped (Table 16) (Hughes and 

Hatsukami 1992). Withdrawal symptoms include restlessness, irritability, anxiety, drowsiness, impatience, 

confusion, impaired concentration, and depression 

(Hughes et al. 1990). Some abstaining smokers 

gain weight, and others have impaired performance 

measures, such as reaction time. Many abstaining 

178 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 16. Incidence* of nicotine withdrawal 

symptoms, United States 

Clinic Selfattendees quitters 

Symptom (%) (%) 

Anxiety 87 49 

Irritability 80 38 

Difficulty concentrating 73 43 

Restlessness 71 46 

Hunger 67 53 

Craving 62 37 

Nocturnal awakenings 24 39 

Depression NA 31 

*Percentage of subjects with postcessation ratings 

greater than precessation ratings 2 days after they 

quit smoking. 

NA = data not available. 

Sources: Hughes 1992; Hughes and Hatsukami 

1992. Adapted from Hughes and Hatsukami 1992. 

smokers have a strong craving to smoke a cigarette. 

Most of the withdrawal symptoms reach maximal intensity 24 to 48 hours after cessation and gradually 

diminish in intensity within three to four weeks (Gross 

and Stitzer 1989; Hughes et al. 1990), although some 

individuals experience longer lasting symptoms 

(USDHHS 1988). These symptoms, which also appear 

after quitting the use of smokeless tobacco (CDC 1994) 

or nicotine gum, are relieved following the administration of nicotine—a strong indication that the withdrawal symptoms are related to the effects of nicotine. 

The degree of nicotine dependence is determined 

in part by the level of nicotine that accumulates in 

smokers. In general, the level of accumulated nicotine 

is proportional to the number of cigarettes smoked per 

day. Consistent with the concept of a daily tolerancewithdrawal cycle, a short duration of time between 

awakening and smoking the first cigarette is associated with a high degree of nicotine dependence 

(Heatherton et al. 1989). This presumably reflects an 

effort to relieve nicotine withdrawal symptoms. These 

two factors—the number of cigarettes smoked per day 

and the amount of time from awakening to smoking 

the first cigarette—are commonly used to assess the 

severity of nicotine dependence (Fagerström and 

Schneider 1989). 

Level of Addiction 

Assessments of the level of nicotine addiction 

help predict responses to nicotine and serve as a 

potential guideline for therapeutic approaches to 

smoking cessation. The professionals who design strategies to prevent tobacco use and treat persons with 

nicotine addiction need to understand the high level 

of addiction among cigarette smokers and to appreciate the group-specific cultural characteristics of the behavior and smokers’ individual reasons for initiating, 

continuing, and quitting tobacco use (Krasnegor 1979; 

Grunberg and Acri 1991). The most widely used indexes of addiction levels are the number of cigarettes 

smoked per day, the serum nicotine or cotinine level, 

the Fagerström dependence questionnaire (Fagerström 

and Schneider 1989), and the diagnostic criteria of the 

DSM-IVTM (APA 1994). The Fagerström dependence 

questionnaire incorporates questions about the number of cigarettes smoked per day, the time between 

awakening and smoking the first cigarette of the day, 

as well as episodes in which the smoker lost control of 

smoking behavior (such as smoking at inappropriate 

times or in inappropriate places). The prevalence of 

smoking cessation—and conversely, the number of 

unsuccessful quit attempts—also reflects the level of 

addiction, at least in part. The brand of cigarette 

smoked might be expected to correlate with a person’s 

level of dependence because high-yield cigarettes 

nominally deliver more nicotine per cigarette. However, in large surveys of smokers, only a modest relationship was found between yield (measured by a 

smoking machine) and levels of nicotine or cotinine in 

the body (Benowitz et al. 1986; Coultas et al. 1993). 

This is because people smoke differently than machines that are set to a standardized testing protocol— 

that is, they are able to take more frequent or deeper 

puffs, to smoke each cigarette more completely, to 

smoke more cigarettes per day, and to block ventilation holes in the cigarettes (Henningfield et al. 1994; 

NCI 1996a). 

Racial/Ethnic Differences in Nicotine Metabolites 

Evidence suggests that African Americans have 

higher cotinine levels per reported number of cigarettes smoked per day than whites (Wagenknecht et 

al. 1990; English et al. 1994; Clark et al. 1996a) (Figure 

5). In Figure 5, the racial/ethnic minority group comparisons among those who smoked 25 or more cigarettes per day may be somewhat biased, because the 

average daily consumption for whites was substantially 

higher than that for African Americans and Mexican 

Health Consequences 179 
 

Surgeon General's Report 

Figure 5.	 Serum cotinine levels by number of cigarettes smoked daily for African Americans, 

Mexican Americans, and whites, National Health and Nutrition Examination Survey, 

United States, 1988–1991 

Cotinine (ng/mL) 

350 

300 

250 

200 

150 

100 

50 

0 

African 

American 

Mexican 

American 

White 

<1 1–<8 8–<15 15–<25 25+ 

Average number of cigarettes smoked per day (past 5 days) 

Note: N = 2,136.
 

Source: National Center for Health Statistics, public use data tape, 1997.
 

Americans. Clark and colleagues (1996b) found no 

evidence that underreporting of daily cigarette consumption occurred more often in African American 

than in white smokers. 

One possible explanation for the higher cotinine 

level among African Americans is that African Americans may absorb more nicotine from their cigarettes 

than whites (Benowitz et al. 1995). Greater absorption could result from several factors, including groupspecific patterns of smoking behavior (i.e., more and 

deeper puffs per cigarette or longer retention of tobacco 

smoke in the lungs) (Benowitz et al. 1995). Additionally, menthol in cigarettes may facilitate absorption of 

cigarette smoke constituents (Jarvik et al. 1994; 

McCarthy et al. 1995; Clark et al. 1996a). However, 

the fact that African Americans smoke menthol cigarettes more commonly than whites do explains only a 

small percentage of their higher levels of cigarette 

smoke constituents (Wagenknecht et al. 1992; 

Ahijevych et al. 1996; Clark et al. 1996a). 

Racial/ethnic differences in nicotine metabolism 

could influence the development of nicotine addiction. 

Several researchers have suggested that African Americans might metabolize cotinine differently than whites 

(Pattishall et al. 1985; Wagenknecht et al. 1990; English 

et al. 1994; Benowitz et al. 1995). Results of studies of 

nonsmokers support this hypothesis (Pattishall et al. 

1985; Wagenknecht et al. 1993; Crawford et al. 1994; 

Knight et al. 1996; Pirkle et al. 1996). Most of these 

investigations (Pattishall et al. 1985; Crawford et al. 

1994; Knight et al. 1996; Pirkle et al. 1996) reported that 

African Americans had higher cotinine levels than 

whites, even after ETS exposure and other factors were 

taken into account. These findings may be limited by 

the fact that no measures of tobacco smoke or nicotine 

concentrations in the air were obtained. 

180 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Based on a preliminary report of data for 40 African Americans and 39 white controls matched for age, 

gender, and cigarette consumption, Benowitz and colleagues (1995) reported that the disposition kinetics 

of nicotine were similar for both groups. For example, 

the percentage conversion of nicotine to cotinine was 

similar across groups. However, the clearance of 

cotinine was significantly lower for African Americans 

than for whites. Additionally, the average estimated 

intake of nicotine per cigarette smoked was 1.41 mg in 

African Americans and 1.09 mg in whites. This difference is of borderline statistical significance (p = 0.07) 

(Benowitz et al. 1995). African Americans took in 28 

percent more nicotine per cigarette than would have 

been expected based on FTC yields; whites took in 9 

percent more nicotine per cigarette than would have 

been expected based on FTC yields (Pérez-Stable et 

al., unpublished data). 

Investigators have also found cotinine levels in 

African Americans that were higher than expected for 

the number of cigarettes smoked. Ahijevych and 

Wewers (1993) found an average salivary cotinine level 

of 402 ng/mL in African American women who 

smoked an average of 15 cigarettes per day. This level 

is much higher than the expected level found in other 

persons who smoked the same number of cigarettes. 

Clark and colleagues (1996b) reported that African 

American smokers smoked longer cigarettes and more 

of each cigarette than white smokers. However, because they smoked fewer cigarettes each day, African 

Americans smoked fewer total daily millimeters of 

cigarettes. Among young adults in the CARDIA study, 

African Americans (48 percent) were more likely than 

whites (36 percent) to report that a substantial amount 

of their cigarette burned without their smoking it 

(Wagenknecht et al. 1992). Also, in a study of 33 African American and white women, Ahijevych and 

colleagues (1996) did not find a racial/ethnic difference in total puff volume (per cigarette). 

Pérez-Stable and colleagues (1990) reported that 

among Mexican Americans who were part of the 

1982–1984 HHANES, cotinine levels were unexpectedly high in smokers reporting low levels of cigarette 

consumption. Higher-than-expected cotinine levels 

may reflect underreporting of smoking by Hispanics, 

but the possibility also exists that Hispanics absorb 

or metabolize nicotine differently than whites 

(Henningfield et al. 1990). However, recent data from 

NHANES III (Figure 5) indicate that, among persons 

who smoked at least one cigarette daily, Mexican 

American smokers had lower serum cotinine levels in 

each consumption category than African American and 

white smokers. 

Racial/Ethnic Differences in Self-Reported 

Nicotine Dependence 

The use of questionnaires to systematically investigate racial/ethnic differences in nicotine dependence has been limited. Data from the 1987 NHIS 

(Table 17) show that African Americans were more 

likely than whites and Hispanics to report smoking 

their first cigarette of the day within 10 minutes of 

awakening, although these differences tended to disappear among those who reported smoking 25 or more 

cigarettes per day (NCHS, public use data tapes, 1987). 

Telephone survey data on smoking, collected as part 

of the Community Intervention Trial (COMMIT) for 

Smoking Cessation, also indicate that African Americans were more likely than whites to smoke within 10 

minutes of awakening (an indicator of nicotine dependence [USDHHS 1988]), even after the researchers controlled for the number of cigarettes smoked per day 

(Royce et al. 1993). Conversely, Andreski and Breslau 

(1993) conducted a study that used the dependence 

criteria of the DSM-IIITM and found that, compared 

with African Americans, greater proportions of whites 

had symptoms of nicotine dependence. The researchers randomly selected 1,200 adults aged 21–30 years 

from the members of a health maintenance organization in southeast Michigan. Overall, 22.6 percent of 

the whites who smoked met the criteria for nicotine 

dependence, compared with 9.3 percent of the African Americans who smoked. Nicotine dependence 

was found to have a significant association with 

psychological distress, as measured by the Brief Symptom Inventory for smokers in both groups. Poor 

physical health was also associated with nicotine dependence, and this relationship was stronger among 

African Americans than among whites. 

Kandel and colleagues (1997) used questions 

from the 1991, 1992, and 1993 (combined) National 

Household Surveys on Drug Abuse (NHSDAs) to develop a proxy measure of DSM-IVTM (APA 1994) dependence on various substances (including nicotine). 

Respondents were asked, for example, if they felt unable to reduce their use when they tried to cut down, 

experienced withdrawal symptoms (described in this 

survey as feeling sick because they stopped or cut 

down), felt that they needed or were dependent on 

the substance, and felt the need for larger amounts to 

obtain the same effect. This study used responses from 

87,915 persons aged 12 years and older. Among persons who smoked during the previous year, whites 

were more likely than African Americans, Hispanics, 

and other racial/ethnic minority group members to 

be rated as dependent on nicotine. The authors 

Health Consequences 181 
 

Surgeon General's Report 

Table 17.	 Percentage of adult smokers* who reported that they smoked their first cigarette within 

10 minutes and within 30 minutes of awakening, by race/ethnicity and number of cigarettes 

smoked per day, National Health Interview Survey, United States, 1987 

African Americans Hispanics Whites ___________________ _________________ ______________ 

Characteristic % ±CI† % ±CI % ±CI 

1–14 cigarettes 

≤10 minutes 21.9 4.9 11.3 5.3 11.1 2.1 

≤30 minutes 39.2 5.5 26.2 7.3 27.1 3.0 

15–24 cigarettes 

≤10 minutes 51.7 8.4 32.7 10.3 36.9 2.4 

≤30 minutes 77.6 5.9 61.3 10.3 68.4 2.5 

≥ 25 cigarettes 

≤10 minutes 69.0 18.0 63.3 17.2 61.9 3.0 

≤30 minutes 95.6 3.6 93.4 8.2 88.8 1.8 

*Persons who reported smoking at least 100 cigarettes in their lives and who reported at the time of survey that 

they currently smoked.

†

95% confidence interval.
 

Source: National Center for Health Statistics, public use data tapes, 1987.
 

acknowledged that their study was limited somewhat 

because the NHSDA indicators of dependence were 

not based on diagnostic interviews designed specifically to assess DSM-IVTM criteria. Nevertheless, the 

finding that whites were more likely to exhibit indicators of dependence than African Americans was consistent with that of Andreski and Breslau (1993). Further research is needed to resolve the apparent discrepancy for African Americans between studies that 

are based on the number of minutes to the first cigarette of the day and those that are based on DSM-IIITM 

or DSM-IVTM criteria for dependence. 

Navarro (1996) used population-based data from 

the 1990 California Tobacco Survey on white (n = 

70,997) and Hispanic (n = 28,000) adults. Her analyses indicated that whites were significantly more likely 

than Hispanics to smoke on a daily basis and to smoke 

at least 15 cigarettes each day. Furthermore, among 

the daily smokers, whites were more likely than 

Hispanics to smoke a cigarette within 30 minutes of 

awakening. Among Hispanics, those who were less 

acculturated (i.e., who came from households where 

the language spoken in the household was not English) 

were significantly less likely than those who were more 

acculturated (i.e., who came from households where 

English was the language spoken) to be daily smokers 

and to smoke at least 15 cigarettes each day. Among 

Hispanics who were daily smokers, the percentage 

who smoked within 30 minutes of awakening did not 

differ significantly by level of acculturation. 

Smoking to maintain a lower body weight is believed to contribute to tobacco dependence. In a survey of high school students in Memphis, Tennessee, 

Camp and colleagues (1993) found that more whites 

than African Americans believed that cigarette smoking could help them control their body weight. Among 

the high school students who smoked, 39 percent of 

white females and 12 percent of white males reported 

smoking to control their body weight, compared with 

none of the African American students. 

A few studies have analyzed the perceptions that 

members of racial/ethnic groups have regarding the 

addictive nature of tobacco. In a San Francisco area 

study of 2,835 primary care patients who smoked, 

Vander Martin and colleagues (1990) found that whites 

smoked more cigarettes per day and were more likely 

to consider themselves addicted to cigarettes than African American, Asian American, and Hispanic smokers. Smoking within 15 minutes of awakening was 

least likely among Hispanic smokers but equally common among smokers in the other groups. In addition, 

African Americans and Hispanics were less likely than 

the others to believe that quitting smoking would lead 

to weight gain. 

182 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Most Americans of all races and ethnicities realize that cigarette smoking is addictive. In a survey of 

2,092 adults in St. Louis and Kansas City, Missouri, 

Brownson and colleagues (1992) found that a similar 

number of whites (90.3 percent) and African Americans (88.5 percent) believed cigarette smoking was 

addictive. Results from the 1992–1993 CPS (see Chapter 5, Research and Development Limitations) showed 

that most members of the four racial/ethnic groups as 

well as whites agreed with the statements that cigarette smoking was an addiction or both a habit and an 

addiction (Table 18) (U.S. Bureau of the Census, NCI 

Tobacco Use Supplement, public use data tapes, 1992– 

1993). Minor differences across gender were observed, 

although smokers were somewhat less likely to agree 

with the statements. Approximately 5 percent of the 

Asian American and Hispanic smokers indicated that 

cigarette smoking was neither a habit nor an addiction, compared with 1.9 percent of white smokers. 

Racial/Ethnic Differences in Quitting Smoking 

Because nicotine is addictive, highly addicted 

smokers have great difficulty in quitting. Differences 

in quitting can be used as another measure of the level 

of dependence. Some studies have found that although 

a similar percentage of whites and African Americans 

have ever been smokers, the percentage of former 

smokers has been greater among whites (26.4 percent) 

than among African Americans (17.2 percent) 

(Novotny et al. 1988) (see also Chapter 2). Data for 

1989 from the BRFSS indicate that the standardized 

prevalence of smoking cessation was 47 percent among 

whites vs. 39.1 percent among African Americans 

(prevalence of cessation was defined as the percentage of ever smokers who were former smokers) (CDC 

1990). Similar findings were reported by Kabat and 

Wynder (1987), Hahn and colleagues (1990), and 

Geronimus and colleagues (1993). The 1991 NHIS 

Health Promotion and Disease Prevention supplement 

collected data on smokers who had quit for at least 

one day at the time of survey and for at least one month 

in the previous year (CDC 1993b). Hispanics (52.1 

percent) and African Americans (48.7 percent) were 

more likely than whites (40.3 percent) to have quit 

smoking for one day. However, data on abstinence 

from smoking in the previous year showed that Hispanics (16.3 percent) and whites (14.0 percent) were 

more likely than African Americans (7.9 percent) to 

have quit smoking for one month or longer. Thus, 

African Americans were less likely than whites to 

maintain abstinence. This effect remained after the 

findings were controlled for socioeconomic status. In 

an unadjusted analysis of data from the Current Population Survey NCI Supplement, a similar pattern 

was observed, although the differences between African Americans and whites were slight (see Table 2 and 

African Americans, Quitting Behavior in Chapter 2). 

The lower smoking cessation rates among African Americans do not appear to result from a lack of 

desire to quit (Royce et al. 1993). In the COMMIT telephone survey, 46.0 percent of African American 

women and 44.4 percent of African American men 

stated that they wanted to quit smoking “a lot,” compared with 35.0 percent of white women and 33.3 percent of white men. Thus, the lower prevalence of 

cessation among African Americans may be related 

to factors other than the desire to quit, such as the 

absence of culturally appropriate smoking cessation 

interventions, difficulties in accessing community 

resources for quitting smoking, and possibly a higher 

level of nicotine dependence as indicated by comparatively higher levels of cotinine when the data are controlled for the number of cigarettes smoked. 

Addiction to Smokeless Tobacco 

Considerable nicotine is absorbed from smokeless tobacco. An average systemic dose of nicotine is 

3.6 mg for snuff, 4.6 mg for chewing tobacco, and 1.8 

mg for cigarettes (Benowitz et al. 1988). Blood nicotine concentrations throughout the day are similar 

among smokers and those who use smokeless tobacco 

(Benowitz et al. 1989a). Plasma cotinine levels in regular smokeless tobacco users are often similar to the levels in cigarette smokers (Holm et al. 1992). Abstinence 

from smokeless tobacco use results in signs and symptoms of nicotine deprivation that are similar to those 

seen in smokers after they stop smoking (Hatsukami 

et al. 1987; CDC 1994). These symptoms are reversed 

by the use of tobacco or administration of nicotine 

gum. In a study of Swedish oral snuff users, many of 

the participants considered themselves addicted to 

snuff, and they reported having as much difficulty giving up smokeless tobacco use as was reported by cigarette smokers trying to quit smoking (Holm et al. 1992). 

Evidence also suggests that when regular snuff users 

are deprived of snuff, they will smoke cigarettes to 

satisfy their need for nicotine (Benowitz 1992b). However, no data are available on racial or ethnic differences in the level of addiction to smokeless tobacco. 

Health Consequences 183 
184 Chapter 3 

Surgeon General's Report 

Table 18.	 Percentage of men and women who considered smoking a habit or addiction,* overall and by 

smoking status, Current Population Survey, United States, 1992–1993 

African 

Americans 

American Indians/ 

Alaska Natives 

Asian Americans/ 

Pacific Islanders Hispanics Whites 

Characteristic %† ±CI‡ % ±CI % ±CI % ±CI % ±CI 

Overall 

Habit 31.7 0.7 19.6 2.6 23.9 1.4 25.1 0.8 17.8 0.2 

Addiction 19.8 0.6 19.6 2.6 17.8 1.2 26.3 0.8 21.9 0.2 

Both 41.3 0.7 54.6 3.3 46.4 1.6 38.4 0.9 57.0 0.3 

Men 

Habit 32.3 1.1 19.5 3.9 25.5 2.0 26.4 1.2 19.3 0.3 

Addiction 20.4 0.9 21.4 4.0 18.4 1.8 26.7 1.2 22.0 0.3 

Both 39.5 1.1 52.6 4.9 45.8 2.3 36.7 1.3 55.2 0.4 

Women 

Habit 31.3 0.9 19.6 3.5 22.5 1.9 24.0 1.0 16.5 0.3 

Addiction 19.5 0.8 18.1 3.4 17.2 1.7 25.9 1.1 21.9 0.3 

Both 42.5 0.9 56.2 4.4 46.9 2.2 39.8 1.2 58.6 0.4 

Nonsmokers

 Habit 29.8 0.8 18.3 3.3 21.7 1.4 23.5 0.8 16.4 0.2 

Addiction 20.4 0.7 21.1 3.5 18.9 1.4 27.1 0.9 23.0 0.3 

Both 42.9 0.8 54.6 4.2 47.5 1.8 39.4 1.0 57.7 0.3 

Men 

Habit 30.3 1.3 19.8 5.3 22.2 2.2 24.6 1.3 18.0 0.4 

Addiction 20.5 1.1 22.4 5.5 20.2 2.1 27.9 1.4 22.8 0.4 

Both 41.6 1.4 51.4 6.6 48.1 2.6 38.0 1.5 56.1 0.5 

Women 

Habit 29.6 1.0 17.3 4.2 21.3 1.9 22.7 1.1 15.0 0.3 

Addiction 20.3 0.9 20.2 4.5 17.8 1.8 26.5 1.1 23.1 0.4 

Both 43.7 1.1 56.8 5.5 47.0 2.4 40.4 1.3 59.0 0.4 

Smokers 

Habit 36.6 1.4 21.5 4.4 36.0 3.9 32.7 2.0 22.1 0.5 

Addiction 18.6 1.1 17.5 4.0 12.3 2.7 22.6 1.7 18.9 0.4 

Both 37.2 1.4 54.4 5.3 40.9 4.0 34.1 2.0 55.2 0.6 

Men 

Habit 36.4 2.0 19.4 5.9 36.6 4.7 32.3 2.5 22.9 0.7 

Addiction 20.2 1.7 20.5 6.1 12.6 3.2 23.3 2.3 19.7 0.6 

Both 35.1 2.0 53.6 7.5 38.3 4.7 32.8 2.5 53.0 0.8 

Women 

Habit 36.7 1.9 23.7 6.4 34.6 7.1 33.2 3.1 21.2 0.7 

Addiction 17.2 1.5 14.4 5.3 11.5 4.8 21.4 2.7 18.1 0.6 

Both 39.0 1.9 55.2 7.5 47.0 7.5 36.1 3.2 57.3 0.8 

*In response to the question, “Do you think smoking is a habit, an addiction, neither, or both?”

†

Percentages in this table do not include all categories of responses and thus may not equal 100%.

‡

95% confidence interval.
 

Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
 

1992–1993.
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Conclusions 

1.	 Cigarette smoking is a major cause of disease and 

death in each of the four racial/ethnic groups studied in this report. African Americans currently 

bear the greatest health burden. Differences in the 

magnitude of disease risk are directly related to 

differences in patterns of smoking. 

2.	 Although lung cancer incidence and death rates 

vary widely among the nation’s racial/ethnic 

groups, lung cancer is the leading cause of cancer 

death for each of the racial/ethnic groups studied 

in this report. Before 1990, death rates from malignant neoplasms of the respiratory system increased 

among African American, Hispanic, and American 

Indian and Alaska Native men and women. From 

1990 through 1995 death rates from respiratory cancers decreased substantially among African American men, leveled off among African American 

women, decreased slightly among Hispanic men 

and women, and increased among American Indian 

and Alaska Native men and women. 

3.	 Rates of tobacco-related cancers (other than lung 

cancer) vary widely among members of racial/ 

ethnic groups, and they are particularly high 

among African American men. 

4.	 The effect of cigarette smoking (as reflected by 

biomarkers of tobacco exposure) on infant birth 

weight appears to be the same in African American 

and white women. As reported in previous Surgeon General’s reports, cigarette smoking increases 

the risk of delivering a low-birth-weight infant. 

Appendix. Methodological Issues 

5.	 No significant racial/ethnic group differences have 

been consistently demonstrated in the relationship 

between smoking and infant mortality or sudden 

infant death syndrome (SIDS); cigarette smoking 

has been associated with increased risk of SIDS 

and remains a probable cause of infant mortality. 

6.	 Future research is needed and should focus on how 

tobacco use affects coronary heart disease, stroke, 

cancer, chronic obstructive pulmonary disease, and 

other respiratory diseases among members of 

racial/ethnic groups. Studies also are needed to 

determine how the health effects of smokeless tobacco use and exposure to environmental tobacco 

smoke vary across racial/ethnic minority groups. 

7.	 Persons of all racial/ethnic backgrounds are vulnerable to becoming addicted to nicotine, and no 

consistent differences exist in the overall severity 

of addiction or symptoms of addiction across 

racial/ethnic groups. 

8.	 Levels of serum cotinine (a biomarker of tobacco 

exposure) are higher in African American smokers than in white smokers for similar levels of daily 

cigarette consumption. Further research is needed 

to clarify the relationship between smoking practices and serum cotinine levels in U.S. racial/ 

ethnic groups. Variables such as group-specific 

patterns of smoking behavior (e.g., number of 

puffs per cigarette, retention time of tobacco smoke 

in the lungs), rates of nicotine metabolism, and 

brand mentholation could be explored. 

It is important to review some methodological 

issues involved in collecting the data discussed in 

this chapter. These methodological problems affect 

the quality of the data and the type of conclusions 

that can be reached from studies conducted to date. 

Also, because cigarette smoking tends to be associated 

with other lifestyle risk factors that impact on health 

(e.g., Wingard et al. 1982; Vickers et al. 1990; PérezStable et al. 1994), there is a need to control their 

co-occurrence in order to better understand the 

health effects of tobacco use. 

Classification of Smoking Status 

In investigating the health effects of smoking 

cigarettes and using other tobacco products, researchers typically obtain information from the subjects or 

surrogate respondents on the use of such products. 

Questionnaires usually cover cigarette smoking status (i.e., never, former, and current smoker), number 

of years of smoking and age at initiation of smoking, 

number of cigarettes smoked per day, and use of other 

tobacco products (e.g., pipes, cigars, and smokeless 

Health Consequences 185 
 

Surgeon General's Report 

tobacco). However, this information may not be fully 

valid, resulting in misclassification of exposure to cigarette smoking. A previous report of the Surgeon General reviewed the classification of cigarette smoking 

status and the consequences of misclassification 

(USDHHS 1990). 

Misclassification of smoking information merits 

consideration in investigating tobacco use among 

racial/ethnic populations, because of the potential for 

bias in comparing the effects of smoking across racial/ 

ethnic groups. To date, such bias has not been identified, although several studies show that Hispanics may 

underreport cigarette smoking. In a population-based 

survey in New Mexico, Coultas and colleagues (1988) 

compared self-reports of smoking against salivary 

cotinine level (a product of nicotine that has been used 

as a measure of exposure to nicotine) and end-tidal carbon monoxide concentration. Based on the questionnaire results, the age-standardized prevalence rates of 

current smoking were 30.9 and 27.1 percent for Hispanic men and women, respectively. After adjusting 

for cotinine and carbon monoxide levels, these percentages were 39.1 and 33.2. The rate of misclassification 

was greater in self-reported former smokers than in 

never smokers, but self-reported never smokers also 

had levels of cotinine and carbon monoxide indicative 

of active smoking. 

Using information from the Hispanic Health and 

Nutrition Examination Survey (HHANES), PérezStable and colleagues (1992) documented the 

misclassification of smoking status through comparisons of self-reports with serum cotinine levels. Among 

65 Mexican American former smokers participating in 

the HHANES in 1982 through 1983, 7 (10.8 percent) 

had a cotinine level indicative of active smoking; 

among 124 reported never smokers, 5 (4 percent) were 

probably active smokers based on their cotinine levels. In a number of surveys, Hispanics, particularly 

Latino groups in the southwestern and western United 

States, have been found to smoke about one-half pack 

of cigarettes per day, compared with non-Hispanic 

whites who typically report smoking one pack per day 

(Coultas et al. 1994). Pérez-Stable and colleagues (1992) 

used data from 547 Mexican American participants in 

the HHANES to examine underreporting of cigarette 

consumption using the ratio of serum cotinine to 

self-reports of the number of cigarettes smoked per 

day as the “gold standard.” This study found that 

among Mexican Americans, 20.4 percent of men 

and 24.7 percent of women who were self-reported 

smokers underreported smoking between one and 

nine cigarettes per day. Self-reported Mexican American smokers who reported smoking greater numbers 

of cigarettes per day underreported less frequently. 

An analysis of the data from the Coronary 

Artery Risk Development in (Young) Adults Study 

(CARDIA) showed that there were higher rates of 

misclassification in terms of self-reported nonsmokers who had serum cotinine levels of at least 14 ng/ 

mL among African Americans (5.7 percent) than 

among non-Hispanic whites (2.8 percent) (Wagenknecht et al. 1992). Alternative explanations for 

underreporting, such as more efficient smoking and 

differences in cotinine metabolism, could not be 

excluded. 

Two additional studies examined the relationship between ancestry of origin and levels of biochemical markers in smokers. In a study of participants in 

CARDIA, African American smokers demonstrated 

higher cotinine levels than non-Hispanic white smokers after controlling for several dimensions of cigarettesmoking behavior (Wagenknecht et al. 1990). Lactose 

intolerance, which elevates breath hydrogen concentration, may increase the apparent level of expired air 

carbon monoxide, a readily measured marker of active smoking (McNeill et al. 1990). Lactose intolerance 

is common in a number of racial/ethnic groups, including Asian Americans and African Americans. 

Classification of Race/Ethnicity 

The data included in this chapter are derived 

from diverse sources, including vital statistics, cancer 

registries, and epidemiological studies on smoking. 

Race/ethnicity has been classified in these studies using various techniques, including designation on death 

certificate, classification according to cancer registry 

protocols, self-reports, birthplace, language use, and 

surname. The validity of each of these approaches is 

undoubtedly imperfect; moreover, validity varies 

across regions and over time. However, comprehensive assessments of the validity of racial/ethnic minority classification in various types of health data 

have not been reported. 

The limited information available indicates some 

potential for misclassification. For example, Frost 

and colleagues (1992) compared the classification of 

“Native American,” as recorded by the Seattle-Puget 

Sound registry of the Surveillance, Epidemiology, and 

End Results (SEER) Program against an Indian Health 

Service (IHS) registry of patients eligible for services. 

A substantial portion of patients with invasive cancer 

in the IHS registry were not similarly classified 

by the Seattle-Puget Sound cancer registry. Similarly, 

an injury registry for the state of Oregon undercounted those with injuries (Sugarman et al. 

1993). Using data from the National Longitudinal 

Mortality Study, Sorlie and colleagues (1992) compared 

demographic characteristics reported on the CPS of the 

186 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

U.S. Bureau of the Census with those characteristics 

reported on the death certificates for persons who died 

(during a seven-year follow-up period). Among 216 

persons identified as American Indians or Alaska 

Natives by the CPS, only 159 (73.6 percent) were so 

classified on the death certificate. Similarly, the concordance rate for 272 persons classified by the CPS as 

Asian Americans or Pacific Islanders was 82.4 percent. 

Such disagreement suggests that current estimates of 

mortality rates for selected racial/ethnic groups are 

underestimated. However, in New Mexico, the classification of “American Indian” by the New Mexico Tumor Registry, also a participant in the SEER Program, 

closely corresponded with the classification by the 

state’s Bureau of Vital Statistics (Eidson et al. 1994). 

Another study in New Mexico also showed a 

high concordance between self-reported Hispanic 

race/ethnicity and the designation by the Bureau of 

Vital Statistics (Samet et al. 1988b). In the report by 

Sorlie and colleagues (1993), 10.3 percent (n = 62) of 

persons identified as Hispanics by the CPS were not 

classified as Hispanics on the death certificate. Surnames also have been used to classify Hispanic 

ethnicity, using either surname lists developed by the 

U.S. Bureau of the Census or name recognition algorithms (Howard et al. 1983; Wiggins and Samet 1993). 

Although studies in parts of the southwestern United 

States have shown a generally high validity for surname-based approaches for identifying Hispanic 

ethnicity, the sensitivity and specificity of the various 

Census Bureau lists have varied over time, and data 

from the Southwest cannot be readily generalized to 

other locales. In addition, surname lists tend to exclude women who marry non-Hispanic whites and 

who take their husband’s last name and to exclude as 

well their children when given the father’s nonHispanic last name (Marín and Marín 1991). 

These studies suggest that the validity of classification of race/ethnicity is likely to vary across locations and possibly by type of data. In interpreting 

health data for racial/ethnic populations, consideration 

should be given to the potential for misclassification 

of race/ethnicity and the consequences of any resulting bias. 

Classification of Health Outcomes 

Comparisons of disease occurrence among 

racial/ethnic groups also may be biased by differential patterns of disease diagnosis and labeling by race 

and ethnicity. Such differences may have multiple 

causes that reflect the complex sequence that begins 

with the development of symptoms and signs and extends to the labeling of an illness by a clinician or the 

statement of cause-of-death on a death certificate. 

Health beliefs and knowledge, ability to access and 

pay for medical care, the quality of care available, and 

differential patterns of care by race/ethnicity may all 

affect diagnoses of illnesses. A full review of these topics is beyond the scope of this report, but several examples are offered to illustrate the potential for differential patterns of classification of health outcomes by 

race/ethnicity. 

Becker and colleagues (1990) examined the assignment of underlying cause of death to the category 

“symptoms, signs, and ill-defined conditions” in the 

Manual of the International Classification of Diseases, Injuries and Causes of Death (ICD). In the nation, the crude 

death rate for this non-specific category has paralleled 

the mortality rate in this category for African Americans. Becker and colleagues (1990) analyzed vital statistics data for New Mexico for 1958 through 1982 and 

calculated mortality rates for “symptoms, signs, and 

ill-defined conditions” by racial/ethnic group. The 

state mortality rates for Hispanics, non-Hispanic 

whites, and American Indians for this category exceeded the nationwide rates. Among the racial/ethnic 

minority groups in New Mexico, American Indians had 

particularly high mortality rates; for men, 8.4 percent 

of American Indian deaths were in this category versus 5.9 percent of Hispanic deaths and 5.0 percent of 

non-Hispanic white deaths. Similarly, mortality rates 

for cancers of ill-defined and unknown primary sites 

tend to be much higher in American Indians in several 

areas of the country than for all racial/ethnic groups 

combined (Valway 1992). 

Recent comparisons of the evaluation and management of chest pain and coronary artery disease in 

African Americans and non-Hispanic whites further 

illustrate the potential for bias by race/ethnicity in diagnostic classification. In a study of patients presenting to an emergency room with chest pain, African 

Americans were less likely to be admitted and less 

likely to be sent to a coronary care unit once they were 

admitted (Johnson et al. 1993). The study also found 

that African Americans were as likely as non-Hispanic 

whites to have cardiac catheterization. In contrast, 

other studies, using Department of Veterans’ Affairs, 

Medicare, and other large data bases, have shown that 

African Americans are less likely than non-Hispanic 

whites to have cardiac catheterization and invasive 

interventions for coronary artery disease (Wenneker 

and Epstein 1989; Udvarhelyi et al. 1992; Ayanian et 

al. 1993; Franks et al. 1993; Whittle et al. 1993; Peterson 

et al. 1994). These differential patterns of evaluation 

by race/ethnicity could introduce bias in investigations 

of tobacco smoking and coronary artery disease among 

African Americans and non-Hispanic whites by 

underestimating the effects of cigarette smoking on 

coronary artery disease. 

Health Consequences 187 
 

Surgeon General's Report 

References 

Abbott RD, Yin Y, Reed DM, Yano K. Rise of stroke in 

male cigarette smokers. New England Journal of Medicine 1986;315(12):717–20. 

Ahijevych K, Wewers ME. Factors associated with nicotine dependence among African American women 

cigarette smokers. Research in Nursing and Health 

1993;16(4):283–92. 

Ahijevych K, Gillespie J, Demirci M, Jagadeesh J. Menthol and nonmenthol cigarettes and smoke exposure 

in black and white women. Pharmacology Biochemistry 

and Behavior 1996;53(2):355–60. 

Alameda County Low Birth Weight Study Group. 

Cigarette smoking and the risk of low birth weight: a 

comparison in black and white women. Epidemiology 

1990;1(3):201–5. 

American Psychiatric Association. Diagnostic and 

Statistical Manual of Mental Disorders, Fourth Edition 

(DSM-IVTM). Washington (DC): American Psychiatric 

Association, 1994. 

Andreski P, Breslau N. Smoking and nicotine dependence in young adults: differences between blacks and 

whites. Drug and Alcohol Dependence 1993;32(2):119–25. 

Anton-Culver H, Lee-Feldstein A, Taylor TH. The association of bladder cancer risk with ethnicity, gender, 

and smoking. Annals of Epidemiology 1993;3(4):429–33. 

Asian American Health Forum, Inc. Asian and Pacific 

Islander American California Proportionate Mortality Ratios. Monograph Series 2. San Francisco: Asian American Health Forum, 1990. 

Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, 

Epstein AM. Racial differences in the use of 

revascularization procedures after coronary angiography. Journal of the American Medical Association 1993; 

269(20):2642–6. 

Ayesh R, Idle JR, Ritchie JC, Crothers MJ, Hetzel MR. 

Metabolic oxidation phenotypes as markers for susceptibility to lung cancer. Nature 1984;312(5990):169–70. 

Bang KM, Gergen PJ, Carroll M. Prevalence of chronic 

bronchitis among U.S. Hispanics from the Hispanic 

Health and Nutrition Examination Survey, 1982–84. 

American Journal of Public Health 1990;80(12):1495–7. 

Baquet CR, Horm JW, Gibbs T, Greenwald P. Socioeconomic factors and cancer incidence among blacks 

and whites. Journal of the National Cancer Institute 

1991;83(8):551–7. 

Baquet CR, Ringen K, Pollack ES, Young JL, Horm JW, 

Ries LAG. Cancer Among Blacks and Other Minorities: 

Statistical Profiles. Bethesda (MD): US Department of 

Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute, Division of Cancer Prevention and Control. NIH 

Publication No. 86-2785, 1986. 

Bardy AH, Seppälä T, Lillsunde P, Kataja JM, Koskela P, 

Pikkarainen J, et al. Objectively measured tobacco exposure during pregnancy: neonatal effects and relation 

to maternal smoking. British Journal of Obstetrics and 

Gynaecology 1993;100(8):721–6. 

Bartsch H, Malaveille C, Friesen M, Kadlubar FF, Vineis P. 

Black (air-cured) and blond (flue-cured) tobacco cancer risk IV: molecular dosimetry studies implicate aromatic amines as bladder carcinogens. European Journal 

of Cancer 1993;29A(8):1199–1207. 

Becerra JE, Smith JC. Maternal smoking and low 

birthweight in the reproductive history of women in 

Puerto Rico, 1982. American Journal of Public Health 

1988;78(3):268–72. 

Beck GJ, Doyle CA, Schachter EN. Smoking and lung 

function. American Review of Respiratory Disease 

1981;123(2):149–55. 

Becker TM, Wheeler CM, McGough NS, Parmenter CA, 

Jordan SW, Stidley CA, et al. Sexually transmitted diseases and other risk factors for cervical dysplasia 

among southwestern Hispanic and non-Hispanic 

white women. Journal of the American Medical Association 1994a;271(15):1181–8. 

188 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Becker TM, Wheeler CM, McGough NS, Parmenter CA, 

Stidley CA, Jamison SF, et al. Cigarette smoking and 

other risk factors for cervical dysplasia in southwestern Hispanic and non-Hispanic white women. Cancer 

Epidemiology, Biomarkers & Prevention 1994b; 

3(2):113–9. 

Becker TM, Wheeler CM, McPherson RS, Kratochvil A, 

Parmenter CA, North CQ, et al. Risk factors for 

cervical dysplasia in southwestern American Indian 

women: a pilot study. Alaska Medicine 1993;35(4): 

255–63. 

Becker TM, Wiggins C, Key CR, Samet JM. Ischemic 

heart disease mortality in Hispanics, American Indians, and non-Hispanic whites in New Mexico, 1958– 

1982. Circulation 1988;78(2):302–9. 

Becker TM, Wiggins CL, Key CR, Samet JM. Symptoms, signs, and ill-defined conditions: a leading cause 

of death among minorities. American Journal of Epidemiology 1990;131(4):664–8. 

Bell DA, Taylor JA, Butler MA, Stephens EA, Wiest J, 

Brubaker LH, et al. Genotype/phenotype discordance 

for human arylamine N-acetyltransferase (NAT2) reveals a new slow-acetylator allele common in AfricanAmericans. Carcinogenesis 1993;14(8):1689–92. 

Benfante R, Reed D, Frank J. Does cigarette smoking 

have an independent effect on coronary heart disease 

incidence in the elderly? American Journal of Public 

Health 1991;81(7):897–9. 

Benowitz NL. Pharmacologic aspects of cigarette 

smoking and nicotine addiction. New England Journal 

of Medicine 1988;319(20):1318–30. 

Benowitz NL. Clinical pharmacology of inhaled drugs 

of abuse: implications in understanding nicotine dependence. In: Chiang CN, Hawks RL, editors. Research 

Findings on Smoking of Abused Substances. National Institute on Drug Abuse Research Monograph No. 99. 

Rockville (MD): US Department of Health and Human 

Services, Public Health Service, Alcohol, Drug Abuse, 

and Mental Health Administration, National Institute 

on Drug Abuse. DHHS Publication No. (ADM) 90­

1690, 1990:12–29. 

Benowitz NL. Cigarette smoking and nicotine addiction. 

Medical Clinics of North America 1992a;76(2):415–37. 

Benowitz NL. Drug therapy—pharmacology of smokeless tobacco use: nicotine addiction and nicotinerelated health consequences. In: Smokeless Tobacco or 

Health: An International Perspective. Smoking and 

Tobacco Control Monograph No. 2. Bethesda (MD): US 

Department of Health and Human Services, Public 

Health Service, National Institutes of Health. NIH 

Publication No. 93-3461, 1992b:219–28. 

Benowitz NL. Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiologic Reviews 

1996;18(2):188–204. 

Benowitz NL, Jacob P III, Jones RT, Rosenberg J. 

Interindividual variability in the metabolism and 

cardiovascular effects of nicotine in man. Journal of 

Pharmacology and Experimental Therapeutics 1982;221 

(2):368–72. 

Benowitz NL, Jacob P III, Yu L. Daily use of smokeless 

tobacco: systemic effects. Annals of Internal Medicine 

1989a;111(2):112–6. 

Benowitz NL, Jacob P III, Yu L, Talcott R, Hall S, Jones RT. 

Reduced tar, nicotine, and carbon monoxide exposure 

while smoking ultralow- but not low-yield cigarettes. 

Journal of the American Medical Association 1986; 

256(2):241–6. 

Benowitz NL, Pérez-Stable E, Herrera B, Jacob P. African American-Caucasian differences in nicotine and 

cotinine metabolism [abstract]. Clinical Pharmacology 

and Therapeutics 1995;57(2):159. 

Benowitz NL, Porchet H, Jacob P III. Nicotine dependence and tolerance in man: pharmacokinetic and 

pharmacodynamic investigations. In: Nordberg A, 

Fuxe K, Holmstedt B, Sundwall A, editors. Progress in 

Brain Research. Vol. 79. Amsterdam: Elsevier Science 

Publishers, 1989b:279–87. 

Benowitz NL, Porchet H, Sheiner L, Jacob P III. Nicotine absorption and cardiovascular effects with 

smokeless tobacco use: comparison with cigarettes and 

nicotine gum. Clinical Pharmacology and Therapeutics 

1988;44(1):23–8. 

Benwell MEM, Balfour DJK, Anderson JM. Evidence 

that tobacco smoking increases the density of (–)-[3H] 

nicotine binding sites in human brain. Journal of Neurochemistry 1988;50(4):1243–7. 

Health Consequences 189 
 

Surgeon General's Report 

Bernstein L, Ross RK. Cancer in Los Angeles County: A 

Portrait of Incidence and Mortality, 1972–1987. Los Angeles: University of Southern California, 1991. 

Blot WJ, Lanier A, Fraumeni JF Jr, Bender TR. Cancer 

mortality among Alaskan Natives, 1960–69. Journal of 

the National Cancer Institute 1975;55(3):547–54. 

Blot WJ, McLaughlin JK, Winn DM, Austin DF, 

Greenberg RS, Preston-Martin S, et al. Smoking and 

drinking in relation to oral and pharyngeal cancer. 

Cancer Research 1988;48(11):3282–7. 

Bolinder G, Alfredsson L, Englund A, de Faire U. 

Smokeless tobacco use and increased cardiovascular 

mortality among Swedish construction workers. 

American Journal of Public Health 1994;84(3):399–404. 

Boyd GM, Glover ED. Smokeless tobacco use by youth 

in the U.S. Journal of School Health 1989;59(5):189–94. 

Braithwaite RL, Taylor SE, editors. Health Issues in the 

Black Community. San Francisco: Jossey-Bass, 1992. 

Brown LM, Hoover RN, Greenberg RS, Schoenberg JB, 

Schwartz AG, Swanson GM, et al. Are racial differences 

in squamous cell esophageal cancer explained by alcohol and tobacco use? Journal of the National Cancer 

Institute 1994;86(17):1340–5. 

Brownson RC, Jackson-Thompson J, Wilkerson JC, 

Davis JR, Owens NW, Fisher EB Jr. Demographic and 

socioeconomic differences in beliefs about the health 

effects of smoking. American Journal of Public Health 

1992;82(1):99–103. 

Buechley R, Dunn JE Jr, Linden G, Breslow L. Excess 

lung-cancer–mortality rates among Mexican women 

in California. Cancer 1957;10(1):63–6. 

Buechley RW, Key CR, Morris DL, Morton WE, Morgan MV. Altitude and ischemic heart disease in 

tricultural New Mexico: an example of confounding. 

American Journal of Epidemiology 1979;109(6):663–6. 

Buell PE, Mendez WM, Dunn JE Jr. Cancer of the lung 

among Mexican immigrant women in California. Cancer 1968;22(1):186–92. 

Burchfiel CM, Marcus EB, Curb JD, Maclean CJ, 

Vollmer WM, Johnson LR, et al. Effects of smoking and 

smoking cessation on longitudinal decline in pulmonary function. American Journal of Respiratory and Critical Care Medicine 1995;151(6):1778–85. 

Burchfiel CM, Marcus EB, Sharp DS, Enright PL, 

Rodriguez BL, Masakai KH, et al. Characteristics associated with rapid decline in forced expiratory volume. Annals of Epidemiology 1996;6(3):217–27. 

Burhansstipanov L, Dresser C. Documentation of the 

Cancer Research Needs of American Indians and Alaska 

Natives. Native American Monograph No. 1. Bethesda 

(MD): Cancer Control Science Program, Division of 

Cancer Prevention and Control, National Cancer Institute. NIH Publication No. 93-3603, 1993. 

Burns PB, Swanson GM. Risk of urinary bladder cancer among blacks and whites: the role of cigarette use 

and occupation. Cancer Causes and Control 1991; 

2(6):371–9. 

Burns PB, Swanson GM. Stomach cancer risk among 

black and white men and women: the role of occupation and cigarette smoking. Journal of Occupational 

and Environmental Medicine 1995;37(10):1218–23. 

Camp DE, Klesges RC, Relyea G. The relationship between body weight concerns and adolescent smoking. 

Health Psychology 1993;12(1):24–32. 

Caporaso NE, Tucker MA, Hoover RN, Hayes RB, 

Pickle LW, Issaq HJ, et al. Lung cancer and the 

debrisoquine metabolic phenotype. Journal of the National Cancer Institute 1990;82(15):1264–72. 

Carmelli D, Swan GE, Robinette D, Fabsitz R. Genetic 

influence on smoking—a study of male twins. 

New England Journal of Medicine 1992;327(12):829–33. 

Castro LC, Azen C, Hobel CJ, Platt LD. Maternal tobacco use and substance abuse: reported prevalence 

rates and associations with the delivery of small for 

gestational age neonates. Obstetrics & Gynecology 

1993;81(3):396–401. 

Centers for Disease Control. Indian Health Service facilities become smoke-free. Morbidity and Mortality 

Weekly Report 1987;36(22):348–50. 

Centers for Disease Control. Prevalence of oral lesions 

and smokeless tobacco use in Northern Plains Indians. Morbidity and Mortality Weekly Report 1988; 

37(39):608–11. 

Centers for Disease Control. Cessation of cigarette 

smoking—United States, 1989. Morbidity and Mortality Weekly Report 1990;39(38):676–80. 

190 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Centers for Disease Control. Discomfort from environmental tobacco smoke among employees at worksites 

with minimal smoking restrictions—United States, 

1988. Morbidity and Mortality Weekly Report 1992; 

41(20):351–4. 

Centers for Disease Control and Prevention. Mortality trends for selected smoking-related cancers and 

breast cancer—United States, 1950–1990. Morbidity and 

Mortality Weekly Report 1993a;42(44):857, 863–6. 

Centers for Disease Control and Prevention. Smoking 

cessation during previous year among adults—United 

States, 1990 and 1991. Morbidity and Mortality Weekly 

Report 1993b;42(26):504–7. 

Centers for Disease Control and Prevention. Use of 

smokeless tobacco among adults—United States, 1991. 

Morbidity and Mortality Weekly Report 1993c; 

42(14):263–6. 

Centers for Disease Control and Prevention. Reasons 

for tobacco use and symptoms of nicotine withdrawal 

among adolescent and young adult tobacco users— 

United States, 1993. Morbidity and Mortality Weekly 

Report 1994;43(41):745–50. 

Chyou PH, Nomura AMY, Stemmermann GN, Kato I. 

Lung cancer: a prospective study of smoking, occupation, and nutrient intake. Archives of Environmental 

Health 1993;48(2):69–72. 

Clark PI, Gautam SP, Gerson LW. Effect of menthol 

cigarettes on biochemical markers of smoke exposure 

among black and white smokers. Chest 1996a; 

110(5):1194–8. 

Clark PI, Gautam S, Hlaing WM, Gerson LW. Response 

error in self-reported current smoking frequency by 

black and white established smokers. Annals of Epidemiology 1996b;6(6):483–9. 

Cloninger CR. Neurogenetic adaptive mechanisms in 

alcoholism. Science 1987;236(4800):410–6. 

Cohen BB, Friedman DJ, Mahan CM, Lederman R, 

Munoz D. Ethnicity, maternal risk, and birth weight 

among Hispanics in Massachusetts, 1987–89. Public 

Health Reports 1993;108(3):363–71. 

Cooper RS, Ford E. Comparability of risk factors for 

coronary heart disease among blacks and whites in the 

NHANES-I Epidemiologic Follow-Up Study. Annals 

of Epidemiology 1992;2(5):637–45. 

Correa P, Fontham E, Pickle LW, Chen V, Lin Y, 

Haenszel W. Dietary determinants of gastric cancer in 

south Louisiana inhabitants. Journal of the National Cancer Institute 1985;75(4):645–54. 

Coultas DB. Other occupational carcinogens. In: Samet JM, 

editor. Epidemiology of Lung Cancer. New York: Marcel 

Dekker, 1994: 299–333. 

Coultas DB, Gong H Jr, Grad R, Handler A, McCurdy SA, 

Player R, et al. Respiratory diseases in minorities of 

the United States. American Journal of Respiratory and 

Critical Care Medicine 1994;149(2):S93–S131. 

Coultas DB, Howard CA, Peake GT, Skipper BJ, Samet JM. 

Discrepancies between self-reported and validated 

cigarette smoking in a community survey of New 

Mexico Hispanics. American Review of Respiratory Disease 1988;137(4):810–14. 

Coultas DB, Samet JM. Occupational lung cancer. Clinics in Chest Medicine 1992;13(2):341–54. 

Coultas DB, Stidley CA, Samet JM. Cigarette yields of 

tar and nicotine and markers of exposure to tobacco 

smoke. American Review of Respiratory Disease 1993; 

148(2):435–40. 

Crawford FG, Mayer J, Santella RM, Cooper TB, 

Ottman R, Tsai WY, et al. Biomarkers of environmental tobacco smoke in preschool children and their mothers. Journal of the National Cancer Institute 1994; 

86(18):1398–402. 

Creagan ET, Fraumeni JF Jr. Cancer mortality among 

American Indians, 1950–67. Journal of the National Cancer Institute 1972;49(4):959–67. 

Crofts F, Cosma GN, Currie D, Taioli E, Toniolo P, Garte ST. 

A novel CYP1A1 gene polymorphism in African 

Americans. Carcinogenesis 1993;14(9):1729–31. 

David MMA, Hanrahan JP, Carey V, Speizer FE, Tager IB. 

Respiratory symptoms in urban Hispanic and nonHispanic white women. American Journal of Respiratory 

and Critical Care Medicine 1996;153(4 Pt 1):1285–91. 

Day GL, Blot WJ, Austin DF, Bernstein L, Greenberg RS, 

Preston-Martin S, et al. Racial differences in risk of oral 

and pharyngeal cancer: alcohol, tobacco, and other 

determinants. Journal of the National Cancer Institute 

1993;85(6):465–73. 

Health Consequences 191 
 

Surgeon General's Report 

Denissenko MF, Pao A, Tang M-s, Pfeifer GP. Preferential formation of benzo[a]pyrene adducts at lung 

cancer mutational hotspots in P53. Science 

1996;274(5286):430–2. 

Desenclos J-CA, Hahn RA. Years of potential life lost 

before age 65, by race, Hispanic origin, and sex— 

United States, 1986–1988. Morbidity and Mortality 

Weekly Report 1992;41(SS-6):13–23. 

DeStefano F, Newman J. Comparison of coronary heart 

disease mortality risk between black and white people 

with diabetes. Ethnicity & Disease 1993;3(2):145–51. 

Devesa SS, Diamond EL. Socioeconomic and racial 

differences in lung cancer incidence. American Journal 

of Epidemiology 1983;118(6):818–31. 

Di Pede C, Viegi G, Quackenboss JJ, Boyer-Pfersdorf P, 

Lebowitz MD. Respiratory symptoms and risk factors 

in an Arizona population sample of Anglo and Mexican American whites. Chest 1991;99(4):916–22. 

Doll R, Peto R, Wheatley K, Gray R, Sutherland I. 

Mortality in relation to smoking: 40 years’ observations on male British doctors. British Medical Journal 

1994;309:901–11. 

Dorgan JF, Ziegler RG, Schoenberg JB, Hartge P, 

McAdams MJ, Falk RT, et al. Race and sex differences 

in associations of vegetables, fruits, and carotenoids 

with lung cancer risk in New Jersey (United States). 

Cancer Causes and Control 1993;4(3):273–81. 

Dunham LJ, Bailar JC III, Laqueur GL. Histologically 

diagnosed cancers in 693 Indians of the United States, 

1950–65. Journal of the National Cancer Institute 1973; 

50(5):1119–27. 

Economou P, Lechner JF, Samet JM. Familial and genetic factors in the pathogenesis of lung cancer. In: 

Samet JM, editor. Epidemiology of Lung Cancer. New 

York: Marcel Dekker, 1994:353–96. 

Edwards G, Arif A, Hodgson R. Nomenclature and 

classification of drug- and alcohol-related problems: a 

shortened version of a WHO memorandum. British 

Journal of Addiction 1982;77(1):3–20. 

Eidson M, Becker TM, Wiggins CL, Key CR, Samet JM. 

Breast cancer among Hispanics, American Indians and 

non-Hispanic whites in New Mexico. International Journal of Epidemiology 1994;23(2):231–7. 

English PB, Eskenazi B. Reinterpreting the effects of 

maternal smoking on infant birthweight and perinatal mortality: a multivariate approach to birthweight 

standardization. International Journal of Epidemiology 

1992;21(6):1097–105. 

English PB, Eskenazi B, Christianson RE. Black-white 

differences in serum cotinine levels among pregnant 

women and subsequent effects on infant birthweight. 

American Journal of Public Health 1994;84(9):1439–43. 

Enos WF, Holmes RH, Beyer J. Coronary disease 

among United States soldiers killed in action in Korea: preliminary report [reprint from 1953]. Journal of 

the American Medical Association 1986;256(20):2859–62. 

Evans R, Mullally DI, Wilson RW, Gergen PJ, 

Rosenberg HM, Grauman JS, et al. National trends in 

the morbidity and mortality of asthma in the U.S.: 

prevalence, hospitalization and death from asthma 

over two decades: 1965–1984. Chest 1987;91(6):65S–74S. 

Fagerström K-O, Götestam KG. Increase of muscle tonus after tobacco smoking. Addictive Behaviors 

1977;2(4):203–6. 

Fagerström K-O, Schneider NG. Measuring nicotine 

dependence: a review of the Fagerstrom Tolerance 

Questionnaire. Journal of Behavioral Medicine 1989; 

12(2):159–82. 

Folsom AR, Johnson KM, Lando HA, McGovern PG, 

Solberg LI, Ekstrum JK. Plasma fibrinogen and other 

cardiovascular risk factors in urban American Indian 

smokers. Ethnicity & Disease 1993;3(4):344–50. 

Franks AL, May DS, Wenger NK, Blount SB, Eaker ED. 

Racial differences in the use of invasive coronary procedures after acute myocardial infarction in Medicare 

beneficiaries. Ethnicity & Disease 1993;3(3):213–20. 

Frerichs RR, Chapman JM, Maes EF. Mortality due to 

all causes and to cardiovascular diseases among seven 

race-ethnic populations in Los Angeles County, 1980. 

International Journal of Epidemiology 1984;13(3):291–8. 

Friedman GD, Tekawa I, Sadler M, Sidney S. Smoking 

and mortality: the Kaiser Foundation experience. In: 

National Cancer Institute. Changes in Cigarette-Related 

Disease Risks and Their Implication for Prevention and 

Control. Smoking and Tobacco Control Monograph No. 

8. Bethesda (MD): US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1997. 

192 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Frost F, Taylor V, Fries E. Racial misclassification of 

Native Americans in a surveillance, epidemiology, and 

end results cancer registry. Journal of the National Cancer Institute 1992;84(12):957–62. 

Garfinkel L. Cigarette smoking and coronary heart disease in blacks: comparison to whites in a prospective 

study. American Heart Journal 1984;108(3 Pt 2):802–7. 

Gerlach KK, Shopland DR, Hartman AM, Gibson JT, 

Pechacek TF. Workplace smoking policies in the United 

States: results from a national survey of more than 

100,000 workers. Tobacco Control 1997;6(3):199–206. 

Geronimus AT, Neidert LJ, Bound J. Age patterns of 

smoking in U.S. black and white women of childbearing age. American Journal of Public Health 1993; 

83(9):1258–64. 

Gillum RF. Ischemic heart disease mortality in American Indians, United States, 1969–1971 and 1979–1981. 

American Heart Journal 1988;115(5):1141–4. 

Giovannucci E, Colditz GA, Stampfer MJ, Hunter D, 

Rosner BA, Willett WC, et al. A prospective study of 

cigarette smoking and risk of colorectal adenoma and 

colorectal cancer in U.S. women. Journal of the National 

Cancer Institute 1994;86(3):192–9. 

Godel JC, Pabst HF, Hodges PE, Johnson KE, Froese GJ, 

Joffres MR. Smoking and caffeine and alcohol intake 

during pregnancy in a northern population: effect on 

fetal growth. Canadian Medical Association Journal 

1992;147(2):181–8. 

Goff DC Jr, Ramsey DJ, Labarthe DR, Nichaman MZ. 

Acute myocardial infarction and coronary heart disease mortality among Mexican Americans and nonHispanic whites in Texas, 1980 through 1989. Ethnicity 

& Disease 1993;3(1):64–9. 

Goldberg RJ, Burchfiel CM, Benfante R, Chiu D, Reed DM, 

Yano K. Lifestyle and biologic factors associated with 

atherosclerotic disease in middle-aged men. 

Archives of Internal Medicine 1995;155(7):686–94. 

Goldstein JA, Faletto MB. Advances in mechanisms of 

activation and deactivation of environmental chemicals. Environmental Health Perspectives 1993;100:169–76. 

Gross J, Stitzer ML. Nicotine replacement: ten-week 

effects on tobacco withdrawal symptoms. Psychopharmacology 1989;98(3):334–41. 

Grunberg NE, Acri JB. Conceptual and methodological considerations for tobacco addiction research. British Journal of Addiction 1991;86(5):637–41. 

Guengerich FP. Characterization of human cytochrome 

P450 enzymes. FASEB Journal 1992;6(2):745–8. 

Guengerich FP. The 1992 Bernard B. Brodie Award 

Lecture: bioactivation and detoxification of toxic and 

carcinogenic chemicals. Drug Metabolism and Disposition 1993;21(1):1–6. 

Hahn LP, Folsom AR, Sprafka JM, Norsted SW. Cigarette smoking and cessation behaviors among urban 

blacks and whites. Public Health Reports 1990; 

105(3):290–5. 

Hames CG, Rose K, Knowles M, Davis CE, Tyroler HA. 

Black-white comparisons of 20-year coronary heart 

disease mortality in the Evans County Heart Study. 

Cardiology 1993;82(2–3):122–36. 

Harris RE, Chen-Backlund J-Y, Wynder EL. Cancer of 

the urinary bladder in blacks and whites: a casecontrol study. Cancer 1990;66(12):2673–80. 

Harris RE, Zang EA, Anderson JI, Wynder EL. Race 

and sex differences in lung cancer risk associated with 

cigarette smoking. International Journal of Epidemiology 

1993;22(4):592–9. 

Hartge P, Silverman DT, Schairer C, Hoover RN. Smoking and bladder cancer risk in blacks and whites in 

the United States. Cancer Causes and Control 1993; 

4(4):391–4. 

Hatsukami DK, Gust SW, Keenan RM. Physiologic and 

subjective changes from smokeless tobacco withdrawal. Clinical Pharmacology and Therapeutics 1987; 

41(1):103–7. 

Heatherton TF, Kozlowski LT, Frecker RC, Rickert W, 

Robinson J. Measuring the heaviness of smoking: using self-reported time to the first cigarette of the day 

and number of cigarettes smoked per day. British Journal of Addiction 1989;84(7):791–800. 

Hebert JR, Kabat GC. Menthol cigarette smoking and 

oesophageal cancer. International Journal of Epidemiology 1989;18(1):37–44. 

Hein DW. Acetylator genotype and arylamine-induced 

carcinogenesis. Biochimica et Biophysica Acta 1988; 

948(1):37–66. 

Health Consequences 193 
 

Surgeon General's Report 

Heishman SJ, Taylor RC, Henningfield JE. Nicotine and 

smoking: a review of effects on human performance. 

Experimental and Clinical Psychopharmacology 1994; 

2(3):1–51. 

Henningfield JE, Cohen C, Giovino GA. Can genetic 

constitution affect the “objective” diagnosis of nicotine dependence? [editorial]. American Journal of Public Health 1990;80(9):1040–1. 

Henningfield JE, Kozlowski LT, Benowitz NL. A proposal to develop meaningful labeling for cigarettes 

[commentary]. Journal of the American Medical Association 1994;272(4):312–4. 

Henningfield JE, Stapleton JM, Benowitz NL, Grayson RF, 

London ED. Higher levels of nicotine in arterial than 

in venous blood after cigarette smoking. Drug and Alcohol Dependence 1993;33(1):23–9. 

Hinds MW, Stemmermann GM, Yang H-Y, Kolonel LN, 

Lee J, Wegner E. Differences in lung cancer risk from 

smoking among Japanese, Chinese and Hawaiian 

women in Hawaii. International Journal of Cancer 

1981;27(3):297–302. 

Hoffman FL. Cancer Among North American Indians. The 

Health Progress of the North American Indian. The Indian 

as a Life Insurance Risk. Newark (NJ): Prudential Press, 

1928. 

Hogue CJ, Yip R. Preterm delivery: can we lower the 

black infant’s first hurdle? Journal of the American Medical Association 1989;262(4):548–50. 

Holck SE, Warren CW, Rochat RW, Smith JC. Lung 

cancer mortality and smoking habits: Mexican American women. American Journal of Public Health 1982; 

72(1):38–42. 

Holm H, Jarvis MJ, Russell MAH, Feyerabend C. Nicotine intake and dependence in Swedish snuff takers. 

Psychopharmacology 1992;108(4):507–11. 

Howard BV, Lee ET, Cowan LD, Fabsitz RR, Howard WJ, 

Oopik AJ, et al. Coronary heart disease prevalence and 

its relation to risk factors in American Indians: the 

Strong Heart Study. American Journal of Epidemiology 

1995;142(3):254–68. 

Howard CA, Samet JM, Buechley RW, Schrag SD, Key 

CR. Survey research in New Mexico Hispanics: some 

methodological issues. American Journal of Epidemiology 1983;117(1):27–34. 

Hughes JR. Genetics of smoking: a brief review. 

Behavior Therapy 1986;17(4):335–45. 

Hughes JR. Tobacco withdrawal in self-quitters. Journal of Consulting and Clinical Psychology 1992;60 

(5):689–97. 

Hughes JR, Hatsukami DK. The nicotine withdrawal 

syndrome: a brief review and update. International Journal of Smoking Cessation 1992;1(2):21–6. 

Hughes JR, Higgins ST, Hatsukami D. Effects of abstinence from tobacco: a critical review. In: Kozlowski 

LT, Annis HM, Cappell HD, Glaser FB, Goodstadt MS, 

Israel Y, et al., editors. Research Advances in Alcohol and 

Drug Problems. Vol. 10. New York: Plenum Publishing 

Corporation, 1990:317–98. 

Humble CG, Samet JM, Pathak DR, Skipper BJ. Cigarette smoking and lung cancer in “Hispanic” whites 

and other whites in New Mexico. American Journal of 

Public Health 1985;75(2):145–8. 

Indian Health Service. Regional Differences in Indian 

Health—1994. Rockville (MD): US Department of 

Health and Human Services, Public Health Service, 

Indian Health Service, Office of Planning, Evaluation, 

and Legislation, Division of Program Statistics, 1994a. 

Indian Health Service. Trends in Indian Health—1994. 

Rockville (MD): US Department of Health and Human 

Services, Public Health Service, Indian Health Service, 

Office of Planning, Evaluation, and Legislation, Division of Program Statistics, 1994b. 

Jacobson JL, Jacobson SW, Sokol RJ, Martier SS, Ager JW, 

Shankaran S. Effects of alcohol use, smoking, and illicit drug use on fetal growth in black infants. Journal 

of Pediatrics 1994;124(5 Pt 1):757–64. 

Jarvik ME, Tashkin DP, Caskey NH, McCarthy WJ, 

Rosenblatt MR. Mentholated cigarettes decrease puff 

volume of smoke and increase carbon monoxide absorption. Physiology and Behavior 1994;56(3):563–70. 

Johnson AA, Knight EM, Edwards CH, Oyemade UJ, 

Cole OJ, Westney OE, et al. Selected lifestyle practices 

in urban African American women—relationships to 

pregnancy outcome, dietary intakes and anthropometric measurements. Journal of Nutrition 1994; 

124(6S):963S–72S. 

194 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Johnson A, Taylor A. National Medical Expenditure Survey. Prevalence of Chronic Diseases: A Summary of Data 

from the Survey of American Indians and Alaska Natives. 

Data Summary 3. Rockville (MD): US Department of 

Health and Human Services, Public Health Service, 

Agency for Health Care Policy and Research, Center 

for General Health Services Intramural Research, 1991. 

Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L. 

Effect of race on the presentation and management of 

patients with acute chest pain. Annals of Internal Medicine 1993;118(8):593–601. 

Kabat GC, Wynder EL. Determinants of quitting 

smoking. American Journal of Public Health 1987; 

77(10):1301–5. 

Kabat GC, Herbert JR. Use of mentholated cigarettes and 

lung cancer risk. Cancer Research 1991;51(24):6510–3. 

Kandel D, Chen K, Warner LA, Kessler RC, Grant B. 

Prevalence and demographic correlates of symptoms 

of last year dependence on alcohol, nicotine, marijuana 

and cocaine in the U.S. population. Drug and Alcohol 

Dependence 1997;44(1):11–29. 

Kattapong VJ, Becker TM. Ethnic differences in mortality from cerebrovascular disease among New 

Mexico’s Hispanics, Native Americans, and nonHispanic whites, 1958 through 1987. Ethnicity & 

Disease 1993;3(1):75–82. 

Kawajiri K, Nakachi K, Imai K, Yoshii A, Shinoda N, 

Watanabe J. Identification of genetically high risk individuals to lung cancer by DNA polymorphisms of 

the cytochrome P4501A1 gene. FEBS Letters 1990; 

263(1):131–3. 

Keenan RM, Hatsukami DK, Pentel PR, Thompson TN, 

Grillo MA. Pharmacodynamic effects of cotinine in 

abstinent cigarette smokers. Clinical Pharmacology and 

Therapeutics 1994;55(5):581–90. 

Keenan RM, Hatsukami DK, Pentel PR, Thompson TN, 

Grillo MA. Evidence that cotinine is psychoactive [reply letter]? Clinical Pharmacology and Therapeutics 

1995;57(1):95–7. 

Keil JE, Sutherland SE, Knapp RG, Lackland DT, Gazes PC, 

Tyroler HA. Mortality rates and risk factors for coronary disease in black as compared with white men and 

women. New England Journal of Medicine 

1993;329(2):73–8. 

Keil JE, Sutherland SE, Hames CG, Lackland DT, Gazes PC, 

Knapp RG, et al. Coronary disease mortality and risk 

factors in black and white men: results from the combined Charleston, SC, and Evans County, Georgia, 

heart studies. Archives of Internal Medicine 

1995;155(14):1521–7. 

Kelsey KT, Wiencke JK, Spitz MR. A race-specific 

genetic polymorphism in the CYP1A1 gene is not 

associated with lung cancer in African Americans. Carcinogenesis 1994;15(6):1121–4. 

Klatsky AL, Armstrong MA, Friedman GD. Racial differences in cerebrovascular disease hospitalizations. 

Stroke 1991;22(3):299–304. 

Klein G, Klein E. Evolution of tumours and the impact of molecular oncology. Nature 1985;315(6016): 

190–5. 

Kleinman JC. Infant mortality among racial/ethnic 

minority groups, 1983–1984. Morbidity and Mortality 

Weekly Report 1990;39(SS-3):31–9. 

Kleinman JC, Pierre MB Jr, Madans JH, Land GH, 

Schramm WF. The effects of maternal smoking on fetal and infant mortality. American Journal of Epidemiology 1988;127(2):274–82. 

Klonoff-Cohen HS, Edelstein SH, Lefkowitz ES, 

Srinivasan IP, Kaegi D, Chang JC, et al. The effect of 

passive smoking and tobacco exposure through breast 

milk on sudden infant death syndrome. Journal of the 

American Medical Association 1995;273(10):795–8. 

Knight JM, Eliopoulos C, Klein J, Greenwald M, Koren G. 

Passive smoking in children: racial differences in systemic exposure to cotinine by hair and urine analysis. 

Chest 1996;109(2):446–50. 

Kolonel LN. Cancer patterns of four ethnic groups in 

Hawaii. Journal of the National Cancer Institute 1980; 

65(5):1127–39. 

Kosary CL, Ries LAG, Miller BA, Hankey BF, Harras A, 

Edwards BK, editors. SEER Cancer Statistics Review, 

1973–1992: Tables and Graphs. Bethesda (MD): US Department of Health and Human Services, Public Health 

Service, National Institutes of Health, National Cancer Institute, Division of Cancer Prevention and Control. NIH Publication No. 96-2789, 1995. 

Health Consequences 195 
 

Surgeon General's Report 

Krasnegor NA. Implications and directions for future 

research. In: Krasnegor NA, editor. Cigarette Smoking 

as a Dependence Process. National Institute on Drug 

Abuse Research Monograph No. 23. Rockville (MD): 

US Department of Health, Education, and Welfare, 

Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug 

Abuse. DHHS Publication No. (ADM) 79-800, 

1979:186–9. 

Kravetz RE. Disease distribution in Southwestern 

American Indians: analysis of 211 autopsies. Arizona 

Medicine 1964;21(9):628–34. 

LaCroix AZ, Haynes SG, Savage DD, Havlik RJ. Rose 

questionnaire angina among United States black, 

white, and Mexican-American women and men. 

American Journal of Epidemiology 1989;129(4):669–86. 

Land H, Parada LF, Weinberg RA. Cellular oncogenes 

and multistep carcinogenesis. Science 1983;222(4625): 

771–8. 

Land GH, Stockbauer JW. Smoking and pregnancy 

outcome: trends among black teenage smokers in Missouri. American Journal of Public Health 1993;83(8): 

1121–4. 

Landi MT, Zocchetti C, Bernucci I, Kadlubar FF, 

Tannenbaum S, Skipper P, et al. Cytochrome P4501A2: 

enzyme induction and genetic control in determining 

4-aminobiphenyl-hemoglobin adduct levels. Cancer 

Epidemiology, Biomarkers & Prevention 1996;5(9):693–8. 

Lanier AP, Bender TR, Blot WJ, Fraumeni JF Jr, 

Hurlburt WB. Cancer incidence in Alaska Natives. International Journal of Cancer 1976;18(4):409–12. 

Lanier AP, Kelly J, Smith B, Amadon C, Harpster A, 

Peters H, et al. Cancer in the Alaska Native Population: 

Eskimo, Aleut, and Indian Incidence and Trends, 1969– 

1988. Anchorage (AK): US Department of Health and 

Human Services, Public Health Service, Indian Health 

Service, Alaska Area Native Health Service, 1993. 

Lanier AP, Kelly JJ, Smith B, Harpster AP, Tanttila H, 

Amadon C, et al. Alaska Native cancer update: incidence rates 1989–1993. Cancer Epidemiology, Biomarkers 

& Prevention 1996;5(9):749–51. 

Le Houezec J, Benowitz NL. Basic and clinical psychopharmacology of nicotine. Clinics in Chest Medicine 

1991;12(4):681–99. 

Le Marchand L, Wilkens LR, Kolonel LN. Ethnic differences in the lung cancer risk associated with smoking. Cancer Epidemiology, Biomarkers & Prevention 1992; 

1(2):103–7. 

Lee ES, Roberts RE, Labarthe DR. Excess and deficit 

lung cancer mortality in three ethnic groups in Texas. 

Cancer 1976;38(6):2551–6. 

Levin ED. Nicotinic systems and cognitive function. 

Psychopharmacology 1992;108(4):417–31. 

Li CQ, Windsor RA, Perkins L, Goldenberg RL, Lowe JB. 

The impact on infant birth weight and gestational age 

of cotinine-validated smoking reduction during pregnancy. Journal of the American Medical Association 

1993;269(12):1519–24. 

Li DK, Daling JR. Maternal smoking, low birth weight, 

and ethnicity in relation to sudden infant death syndrome. American Journal of Epidemiology 1991;134 

(9):958–64. 

Lieberman E, Gremy I, Lang JM, Cohen AP. Low 

birthweight at term and the timing of fetal exposure 

to maternal smoking. American Journal of Public Health 

1994;84(7):1127–31. 

London SJ, Daly AK, Fairbrother KS, Holmes C, Carpenter CL, Navidi WC, et al. Lung cancer risk in 

African-Americans in relation to a race-specific 

CYP1A1 polymorphism. Cancer Research 1995; 

55(24):6035–7. 

Lubs ML. Racial differences in maternal smoking 

effects on the newborn infant. American Journal of 

Obstetrics and Gynecology 1973;115(1):66–76. 

Mahoney MC, Michalek AM. A meta-analysis of cancer incidence in United States and Canadian Native 

populations. International Journal of Epidemiology 

1991;20(2):323–7. 

Mallin K, Anderson K. Cancer mortality in Illinois 

Mexican and Puerto Rican immigrants, 1979–1984. 

International Journal of Cancer 1988;41(5):670–6. 

Malloy MH, Kleinman JC, Land GH, Schramm WF. 

The association of maternal smoking with age and 

cause of infant death. American Journal of Epidemiology 

1988;128(1):46–55. 

196 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Mannino DM, Brown C, Giovino GA. Obstructive lung 

disease deaths in the United States from 1979 through 

1993: an analysis using multiple-cause mortality data. 

American Journal of Respiratory and Critical Care Medicine 1997;156(3):814–8. 

Marcus EB, Buist AS, Curb JD, Maclean CJ, Reed DM, 

Johnson LR, et al. Correlates of FEV1 and prevalence 

of pulmonary conditions in Japanese-American men. 

American Review of Respiratory Disease 1988; 

138(6):1398–404. 

Marín G, Marín BV. Research with Hispanic Populations. 

Applied Social Research Methods Series. Vol. 23. 

Newbury Park (CA): Sage Publications, 1991. 

Marks MJ, Campbell SM, Romm E, Collins AC. 

Genotype influences the development of tolerance to 

nicotine in the mouse. Journal of Pharmacology and Experimental Therapeutics 1991;259(1):392–402. 

Marks MJ, Stitzel JA, Collins AC. Time course study 

of the effects of chronic nicotine infusion on drug response and brain receptors. Journal of Pharmacology and 

Experimental Therapeutics 1985;235(3):619–28. 

Marshall CJ, Vousden KH, Phillips DH. Activation of 

c-Ha-ras-1 proto-oncogene by in vitro modification 

with a chemical carcinogen, benzo(a)pyrene diolepoxide. Nature 1984;310(5978):586–9. 

Martin J, Suarez L. Cancer mortality among Mexican 

Americans and other whites in Texas, 1969–80. American Journal of Public Health 1987;77(7):851–3. 

Mattson ME, Winn DM. Smokeless tobacco: association with increased cancer risk. In: Smokeless Tobacco 

Use in the United States. National Cancer Institute 

Monographs No. 8. Bethesda (MD): US Department 

of Health and Human Services, Public Health Service, 

National Institutes of Health. NIH Publication No. 

89-3055, 1989:5–16. 

McCarthy WJ, Caskey NH, Jarvik ME, Gross TM, 

Rosenblatt MR, Carpenter C. Menthol vs. nonmenthol 

cigarettes: effects on smoking behavior. American Journal of Public Health 1995;85(1):67–72. 

McKennell AC. Smoking motivation factors. British 

Journal of Social and Clinical Psychology 1970;9(1):8–22. 

McNeill AD, Owen LA, Belcher M, Sutherland G, 

Fleming S. Abstinence from smoking and expired-air 

carbon monoxide levels: lactose intolerance as a possible source of error. American Journal of Public Health 

1990;80(9):1114–5. 

McWhorter WM, Polis MA, Kaslow RA. Occurrence, 

predictors, and consequences of adult asthma in 

NHANESI and follow-up survey. American Review of 

Respiratory Disease 1989;139(3):721–4. 

Menck HR, Henderson BE, Pike MC, Mack T, Martin SP, 

SooHoo J. Cancer incidence in the Mexican American. 

Journal of the National Cancer Institute 1975;55 

(3):531–6. 

Middaugh JP. Cardiovascular deaths among Alaskan 

Natives, 1980–86. American Journal of Public Health 

1990;80(3):282–5. 

Miller EC, Miller JA. Searches for the ultimate chemical carcinogens and their reactions with cellular macromolecules. Cancer 1981;47(10):2327–45. 

Miller GE, Jarvik ME, Caskey NH, Segerstrom SC, 

Rosenblatt MR, McCarthy WJ. Cigarette mentholation 

increases smokers’ exhaled carbon monoxide levels. 

Experimental and Clinical Psychopharmacology 1994; 

2(2):154–60. 

Mitchell BD, Hazuda HP, Haffner SM, Patterson JK, 

Stern MP. Myocardial infarction in Mexican Americans 

and non-Hispanic whites: the San Antonio Heart Study. 

Circulation 1991;83(1):45–51. 

National Cancer Institute. Tobacco Effects in the Mouth. 

Bethesda (MD): US Department of Health and Human 

Services, Public Health Service, National Institutes of 

Health, National Cancer Institute and National Institute of Dental Research. NIH Publication No. 92-3330, 

1992. 

National Cancer Institute. The FTC Cigarette Test Method 

for Determining Tar, Nicotine, and Carbon Monoxide Yields 

of US Cigarettes. Report of the NCI Expert Committee. 

Smoking and Tobacco Control Monograph No. 7. 

Bethesda (MD): US Department of Health and Human 

Services, Public Health Service, National Institutes of 

Health, National Cancer Institute. NIH Publication No. 

96-4028, 1996a. 

Health Consequences 197 
 

Surgeon General's Report 

National Cancer Institute. Racial/Ethnic Patterns of Cancer in the United States, 1988–1992. Bethesda (MD): US 

Department of Health and Human Services, Public 

Health Service, National Institutes of Health, National 

Cancer Institute, Division of Cancer Prevention and 

Control. NIH Publication No. 96-4104, 1996b. 

National Center for Health Statistics. Current Estimates 

From the National Health Interview Survey, 1990. 

Vital and Health Statistics. Series 10, No. 181. Hyattsville 

(MD): US Department of Health and Human Services, 

Public Health Service, Centers for Disease Control, 

National Center for Health Statistics. DHHS Publication No. (PHS) 92-1509, 1991. 

National Center for Health Statistics. Advance Report 

of Final Mortality Statistics, 1990. Monthly Vital Statistics Report 1993;41(7 Suppl). 

National Center for Health Statistics. Health, United 

States, 1993. Hyattsville (MD): US Department of 

Health and Human Services, Public Health Service, 

Centers for Disease Control and Prevention, National 

Center for Health Statistics. DHHS Publication No. 

(PHS) 94-1232, 1994. 

National Center for Health Statistics. Advance Report 

of Final Mortality Statistics, 1994. Monthly Vital Statistics Report 1996a;45(3 Suppl). 

National Center for Health Statistics. Health, United 

States, 1995. Hyattsville (MD): US Department of 

Health and Human Services, Public Health Service, 

Centers for Disease Control and Prevention, National 

Center for Health Statistics. DHHS Publication No. 

(PHS) 96-1232, 1996b. 

National Center for Health Statistics. Health, United 

States, 1996–97 and Injury Chartbook. Hyattsville (MD): 

US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. DHHS Publication No. (PHS) 

97-1232, 1997. 

National Research Council. Environmental Tobacco 

Smoke: Measuring Exposures and Assessing Health Effects. 

Washington (DC): National Academy Press, 1986. 

Navarro AM. Cigarette smoking among adult Latinos: 

the California Tobacco Baseline Survey. Annals of Behavioral Medicine 1996;18(4):238–45. 

Neggers Y, Goldenberg RL, Cliver SP, Hoffman HJ, 

Copper RI. The relationship between maternal skinfold 

thickness, smoking and birthweight in black and white 

women. Paediatric and Perinatal Epidemiology 1994; 

8(2):216–21. 

Nomura AMY, Stemmermann GN, Chyou PH. Gastric cancer among the Japanese in Hawaii. Japanese Journal of Cancer Research 1995;86(10):916–23. 

Novotny TE, Warner KE, Kendrick JS, Remington PL. 

Smoking by blacks and whites: socioeconomic and 

demographic differences. American Journal of Public 

Health 1988;78(9):1187–9. 

Nutting PA, Freeman WL, Risser DR, Helgerson SD, 

Paisano R, Hisnanick J, et al. Cancer incidence among 

American Indians and Alaska Natives, 1980 through 

1987. American Journal of Public Health 1993; 

83(11):1589–98. 

Ochsner A, DeBakey M. Symposium on cancer. 

Primary pulmonary malignancy. Treatment by total 

pneumonectomy; analysis of 79 collected cases and 

presentation of 7 personal cases. Surgery, Gynecology, 

and Obstetrics 1939;68(2):435–51. 

Overpeck MD, Moss AJ. Children’s Exposure to Environmental Cigarette Smoke Before and After Birth: 

Health of Our Nation’s Children, United States, 1988. 

Advance Data. No. 202. Hyattsville (MD): US Department of Health and Human Services, Public Health 

Service, Centers for Disease Control, National Center 

for Health Statistics, 1991. 

Parker CL, Tong T, Bolden BA, Wingo PA. Cancer 

statistics, 1997. CA: A Cancer Journal for Clinicians 

1997;47(1):5–27. 

Pattishall EN, Strope GL, Etzel RA, Helms RW, Haley NJ, 

Denny FW. Serum cotinine as a measure of tobacco 

smoke exposure in children. American Journal of Diseases of Children 1985;139(11):1101–4. 

Peeke SC, Peeke HVS. Attention, memory, and cigarette smoking. Psychopharmacology 1984;84(2):205–16. 

Pérez-Stable EJ, Marín G, Marín BV, Benowitz NL. 

Misclassification of smoking status by self-reported 

cigarette consumption. American Review of Respiratory 

Disease 1992;145(1):53–7. 

198 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Pérez-Stable EJ, Marín G, Marín BV. Behavioral risk 

factors: a comparison of Latinos and non-Latino whites 

in San Francisco. American Journal of Public Health 1994; 

84(6):971–6. 

Pérez-Stable EJ, Vanoss Marín B, Marín G, Brody DJ, 

Benowitz NL. Apparent underreporting of cigarette 

consumption among Mexican American smokers. 

American Journal of Public Health 1990;80(9):1057–61. 

Peters RK, Thomas D, Hagan DG, Mack TM, 

Henderson BE. Risk factors for invasive cervical cancer among Latinas and non-Latinas in Los Angeles 

County. Journal of the National Cancer Institute 1986; 

77(5):1063–77. 

Peterson ED, Wright SM, Daley J, Thibault GE. Racial 

variation in cardiac procedure use and survival following acute myocardial infarction in the Department 

of Veterans Affairs. Journal of the American Medical 

Association 1994;271(15):1175–80. 

Pickworth WB, Herning RI, Henningfield JE. Spontaneous EEG changes during tobacco abstinence and 

nicotine substitution in human volunteers. Journal of 

Pharmacology and Experimental Therapeutics 1989; 

251(3):976–82. 

Pierce JP, Cavin SW, Macky C, Rosbrook B, Berry CC, 

Maklan DM, et al. Technical Report on Analytic Methods 

and Approaches Used in the 1992 California Tobacco Survey Analysis. Sacramento (CA): California Department 

of Health Services, 1994. 

Pirkle JL, Flegal KM, Bernert JT, Brody DJ, Etzel RA, 

Maurer KR. Exposure of the U.S. population to environmental tobacco smoke: the third National Health 

and Nutrition Examination Survey, 1988–1991. Journal of the American Medical Association 1996; 

275(16):1233–40. 

Polednak AP. Cancer incidence in the Puerto Ricanborn population of Long Island, New York. American 

Journal of Public Health 1991;81(11):1405–7. 

Polednak AP. Lung cancer rates in the Hispanic population of Connecticut, 1980–88. Public Health Reports 

1993;108(4):471–6. 

Pomerleau OF, Pomerleau CS. Neuroregulators and the 

reinforcement of smoking: towards a biobehavioral 

explanation. Neuroscience and Biobehavioral Reviews 

1984;8(4):503–13. 

Pomerleau CS, Pomerleau OF, Majchrzak MJ, Kloska DD, 

Malakuti R. Relationship between nicotine tolerance 

questionnaire scores and plasma cotinine. Addictive 

Behaviors 1990;15(1):73–80. 

Pottern LM, Morris LE, Blot WJ, Ziegler RG, Fraumeni JF Jr. Esophageal cancer among black men in 

Washington, D.C. Alcohol, tobacco, and other risk 

factors. Journal of the National Cancer Institute 1981; 

67(4):777–83. 

Pritchard WS, Robinson JH, Guy TD. Enhancement of 

continuous performance task reaction time by smoking in non-deprived smokers. Psychopharmacology 

1992;108(4):437–42. 

Reed DM. The paradox of high risk of stroke in populations with low risk of coronary heart disease. American Journal of Epidemiology 1990;131(4):579–88. 

Reed DM, MacLean CJ, Hayashi T. Predictors of atherosclerosis in the Honolulu Heart Program. I: biologic, 

dietary, and lifestyle characteristics. American Journal 

of Epidemiology 1987;126(2):214–25. 

Reed D, McGee D, Cohen J, Yano K, Syme SL, Feinleib M. 

Acculturation and coronary heart disease among Japanese men in Hawaii. American Journal of Epidemiology 

1982;115(6):894–905. 

Reed D, McGee D, Yano K. Trends of coronary heart 

disease among men of Japanese ancestry in Hawaii. 

Journal of Community Health 1983;8(3):149–59. 

Reichenbach DD. Autopsy incidence of diseases 

among Southwestern American Indians. Archives of 

Pathology 1967;84(July):81–6. 

Rewers M, Shetterly SM, Hoag S, Baxter J, Marshall J, 

Hamman RF. Is the risk of coronary heart disease lower 

in Hispanics than in non-Hispanic whites? The San 

Luis Valley diabetes study. Ethnicity & Disease 

1993;3(1):44–54. 

Rhoades ER. The major respiratory diseases of American Indians. American Review of Respiratory Disease 

1990;141(3):595–600. 

Richie JP, Carmella SG, Muscat JE, Scott DG, Akerkar SA, 

Hecht SS. Differences in the urinary metabolites of the tobacco-specific lung carcinogen 

4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone in 

black and white smokers. Cancer Epidemiology, 

Biomarkers & Prevention 1997;6(10):783–90. 

Health Consequences 199 
 

Surgeon General's Report 

Ries LAG, Kosary CL, Hankey BF, Miller BA, Harras A, 

Edwards BK, editors. SEER Cancer Statistics Review, 

1973–1994. Bethesda (MD): US Department of Health 

and Human Services, Public Health Service, National 

Institutes of Health, National Cancer Institute. NIH 

Publication No. 97-2789, 1997. 

Rodriguez BL, Sharp DS, Abbott RD, Burchfiel CM, 

Masaki K, Chyou PH, et al. Fish intake may limit the 

increase in risk of coronary heart disease morbidity 

and mortality among heavy smokers. Circulation 

1996;94(5):952–6. 

Rosenberg MJ, editor. Smoking and Reproductive Health. 

Littleton (MA): PSG Publishing Company, 1987. 

Rosenwaike I. Mortality differentials among persons 

born in Cuba, Mexico, and Puerto Rico residing in the 

United States, 1979–81. American Journal of Public Health 

1987;77(5):603–6. 

Ross RK, Bernstein L, Hartnett NM, Boone JR. Cancer 

patterns among Vietnamese immigrants in Los Angeles County. British Journal of Cancer 1991;64(1):185–6. 

Royce JM, Hymowitz N, Corbett K, Hartwell TD, 

Orlandi MA. Smoking cessation factors among African Americans and whites. American Journal of Public 

Health 1993;83(2):220–6. 

Russell MAH, Peto J, Patel UA. The classification of 

smoking by factorial structure of motives. Journal of 

the Royal Statistical Society 1974;137(Pt 3, Series A): 

313–46. 

Salsbury CG, Howard FH, Bassford PS Jr, Atkinson GR, 

Green RW. A cancer detection survey of carcinoma of 

the lung and female pelvis among Navajos on the 

Navajo Indian reservation. Surgery, Gynecology and 

Obstetrics 1959;108(3):257–66. 

Samet JM. Definitions and methodology in COPD research. In: Hensley MJ, Saunders NA, editors. Clinical 

Epidemiology of Chronic Obstructive Pulmonary Disease. 

New York: Marcel Dekker, 1989:1–22. 

Samet JM. The epidemiology of lung cancer. Chest 

1993;103(1 Suppl):20S–29S. 

Samet JM, Coultas DB, Howard CA, Skipper BJ. Respiratory disease and cigarette smoking in a Hispanic 

population in New Mexico. American Review of Respiratory Disease 1988a;137(4):815–9. 

Samet JM, Key CR, Kutvirt DM, Wiggins CL. Respiratory disease mortality in New Mexico’s American Indians and Hispanics. American Journal of Public Health 

1980;70(5):492–7. 

Samet JM, Schrag SD, Howard CA, Key CR, Pathak 

DR. Respiratory disease in a New Mexico population 

sample of Hispanic and non-Hispanic whites. American Review of Respiratory Disease 1982;125(2):152–7. 

Samet JM, Wiggins CL, Key CR, Becker TM. Mortality 

from lung cancer and chronic obstructive pulmonary 

disease in New Mexico, 1958–82. American Journal of 

Public Health 1988b;78(9):1182–6. 

Saracci R, Boffetta P. Interactions of tobacco smoking 

with other causes of lung cancer. In: Samet JM, editor. 

Epidemiology of Lung Cancer. New York: Marcel Dekker, 

1994:465–93. 

Saunders E, editor. Cardiovascular Diseases in Blacks. 

Philadelphia: F.A. Davis Company, 1991. 

Savitz DA. Changes in Spanish surname cancer rates 

relative to other whites, Denver area, 1969–71 to 

1979–81. American Journal of Public Health 1986; 

76(10):1210–5. 

Schoen R, Nelson VE. Mortality by cause among Spanish surnamed Californians, 1969–71. Social Science 

Quarterly 1981;62(2):259–74. 

Schoendorf KC, Kiely JL. Relationship of sudden infant death syndrome to maternal smoking during and 

after pregnancy. Pediatrics 1992;90(6):905–8. 

Schwartz AG, Swanson GM. Lung carcinoma in African Americans and whites: a population-based study 

in metropolitan Detroit, Michigan. Cancer 1997; 

79(1):45–52. 

Sharp DS, Rodriguez BL, Shahar E, Hwang LJ, 

Burchfiel CM. Fish consumption may limit the damage of smoking on the lung. American Journal of Respiratory and Critical Care Medicine 1994;150(4):983–7. 

Shea S, Stein AD, Basch CE, Lantigua R, Maylahn C, 

Strogatz DS, et al. Independent associations of educational attainment and ethnicity with behavioral risk 

factors for cardiovascular disease. American Journal of 

Epidemiology 1991;134(6):567–82. 

200 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Shields PG, Caporaso NE, Falk RT, Sugimura H, Trivers GE, 

Trump BF, et al. Lung cancer, race, and a CYP1A1 genetic polymorphism. Cancer Epidemiology, Biomarkers 

& Prevention 1993;2(5):481–5. 

Shopland DR. Tobacco use and its contribution to early 

cancer mortality with a special emphasis on cigarette 

smoking. Environmental Health Perspectives 1995; 

103(Suppl 8):131–41. 

Sidney S, Tekawa IS, Friedman GD, Sadler MC, Tashkin DP. 

Mentholated cigarette use and lung cancer. Archives of 

Internal Medicine 1995;155(7):727–32. 

Siegel M. Smoking and leukemia: evaluation of a causal 

hypothesis. American Journal of Epidemiology 1993; 

138(1):1–9. 

Sievers ML, Cohen SL. Lung cancer among Indians of 

the Southwestern United States. Annals of Internal Medicine 1961;54(5):912–5. 

Slamon DJ, deKernion JB, Verma IM, Cline MJ. Expression of cellular oncogenes in human malignancies. 

Science 1984;224(4646):256–62. 

Smith RL. Recorded and expected mortality among the 

Indians of the United States with special reference to 

cancer. Journal of the National Cancer Institute 1957; 

18(3):385–96. 

Smith CA, Pratt M. Cardiovascular disease. In: 

Brownson RC, Remington PL, Davis JR, editors. 

Chronic Disease Epidemiology and Control. Washington 

(DC): American Public Health Association, 1993: 

83–107. 

Smith RL, Salsbury CG, Gilliam AG. Recorded and 

expected mortality among the Navajo, with special 

reference to cancer. Journal of the National Cancer Institute 1956;17(1):77–89. 

Snyder FR, Davis FC, Henningfield JE. The tobacco 

withdrawal syndrome: performance decrements 

assessed on a computerized test battery. Drug and 

Alcohol Dependence 1989;23(3):259–66. 

Snyder FR, Henningfield JE. Effects of nicotine administration following 12 h of tobacco deprivation: assessment on computerized performance tasks. Psychopharmacology 1989;97(1):17–22. 

Sorem KA. Cancer incidence in the Zuni Indians of 

New Mexico. Yale Journal of Biology and Medicine 

1985;58(5):489–96. 

Sorlie PD, Backlund E, Johnson NJ, Rogot E. Mortality 

by Hispanic status in the United States. Journal of the 

American Medical Association 1993;270(20):2464–8. 

Sorlie PD, Rogot E, Johnson NJ. Validity of demographic characteristics on the death certificate. Epidemiology 1992;3(2):181–4. 

Spitz MR, Hsu TC, Wu X, Fueger JJ, Amos CI, Roth JA. 

Mutagen sensitivity as a biological marker of lung cancer risk in African Americans. Cancer Epidemiology, 

Biomarkers & Prevention 1995;4(2):99–103. 

Stern MP, Bradshaw BS, Eifler CW, Fong DS, Hazuda HP, 

Rosenthal M. Secular decline in death rates due to ischemic heart disease in Mexican Americans and nonHispanic whites in Texas, 1970–1980. Circulation 

1987;76(6):1245–50. 

Stern MP, Gaskill SP. Secular trends in ischemic heart 

disease and stroke mortality from 1970 to 1976 in Spanish-surnamed and other white individuals in Bexar 

County, Texas. Circulation 1978;58(3):537–43. 

Strom SS, Wu X, Sigurdson AJ, Hsu TC, Fueger JJ, 

Lopez J, et al. Lung cancer, smoking patterns, and 

mutagen sensitivity in Mexican-Americans. Journal of 

the National Cancer Institute Monographs 1995; 

18(18):29–33. 

Strong JP. Coronary atherosclorosis in soldiers: a clue 

to the natural history of atherosclerosis in the young. 

Journal of the American Medical Association 1986; 

256(20):2863–6. 

Sugarman JR, Soderberg R, Gordon JE, Rivara FP. 

Racial misclassification of American Indians: its effect 

on injury rates in Oregon, 1989 through 1990. American Journal of Public Health 1993;83(5):681–4. 

Sugarman JR, Warren CW, Oge L, Helgerson SD. Using the behavioral risk factor surveillance system to 

monitor year 2000 objectives among American Indians. Public Health Reports 1992;107(4):449–56. 

Sutherland G, Stapleton JA, Russell MAH, Jarvis MJ, 

Hajek P, Belcher M, et al. Randomised controlled trial 

of nasal nicotine spray in smoking cessation. Lancet 

1992;340(8815):324–9. 

Health Consequences 201 
 

Surgeon General's Report 

Taioli E, Crofts F, Trachman J, Demopoulos R, Toniolo P, 

Garte SJ. A specific African-American CYP1A1 polymorphism is associated with adenocarcinoma of the 

lung. Cancer Research 1995;55(3):472–3. 

Tolley HD, Crane L, Shipley N. Smoking prevalence and 

lung cancer death rates. In: Strategies to Control Tobacco 

Use in the United States—A Blueprint for Public Health 

Action in the 1990s. Bethesda (MD): US Department of 

Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute. 

DHHS Publication No. (NIH) 92-3316, 1991. 

Tomar SL, Winn DM, Swango PA, Giovino GA, 

Kleinman DV. Oral mucosal smokeless tobacco lesions 

among adolescents in the United States. Journal of Dental Research 1997;76(6):1277–86. 

Trapido EJ, Chen F, Davis K, Lewis N, MacKinnon JA. 

Cancer among Hispanic males in South Florida: nine 

years of incidence data. Archives of Internal Medicine 

1994a;154(2):177–85. 

Trapido EJ, Chen F, Davis K, Lewis N, MacKinnon JA, 

Strait PM. Cancer in South Florida Hispanic women: 

a 9-year assessment. Archives of Internal Medicine 

1994b;154(10):1083–8. 

Trapido EJ, McCoy CB, Stein NS, Engel S, McCoy HV, 

Olejniczak S. The epidemiology of cancer among Hispanic women: the experience in Florida. Cancer 

1990a;66(11):2435–41. 

Trapido EJ, McCoy CB, Stein NS, Engel S, Zavertnik JJ, 

Comerford M. Epidemiology of cancer among Hispanic males: the experience in Florida. Cancer 

1990b;65(7):1657–62. 

Tyroler HA, Knowles MG, Wing SB, Logue EE, Davis CE, 

Heiss G, et al. Ischemic heart disease risk factors and 

twenty-year mortality in middle-age Evans County 

black males. American Heart Journal 1984;108(3 Pt 

2):738–46. 

Udvarhelyi IS, Gatsonis C, Epstein AM, Pashos CL, 

Newhouse JP, McNeil BJ. Acute myocardial infarction 

in the Medicare population. Journal of the American 

Medical Association 1992;268(18):2530–6. 

US Bureau of the Census. Current Population Reports: 

U.S. Population Estimates, by Age, Sex, Race, and Hispanic 

Origin: 1980 to 1991. Washington (DC): US Government 

Printing Office. Publication No. P25-1095, 1993. 

US Bureau of the Census. State Population Estimates 

by Age, Sex, Race, and Hispanic Origin: 1990–1994; 

<http://www/census.gov/population/www/ 

estimates/st_sasrh.html>; (accessed: August 21, 1997). 

US Department of Health and Human Services. The 

Health Consequences of Smoking for Women. A Report of 

the Surgeon General. Rockville (MD): US Department 

of Health and Human Services, Public Health Service, 

Office of the Assistant Secretary for Health, Office on 

Smoking and Health, 1980. 

US Department of Health and Human Services. The 

Health Consequences of Smoking: Cardiovascular Disease. 

A Report of the Surgeon General. Rockville (MD): US 

Department of Health and Human Services, Public 

Health Service, Office on Smoking and Health. DHHS 

Publication No. (PHS) 84-50204, 1983. 

US Department of Health and Human Services. The 

Health Consequences of Smoking: Chronic Obstructive 

Lung Disease. A Report of the Surgeon General. Rockville 

(MD): US Department of Health and Human Services, 

Public Health Service, Office on Smoking and Health. 

DHHS Publication No. (PHS) 84-50205, 1984. 

US Department of Health and Human Services. The 

Health Consequences of Involuntary Smoking. A Report of 

the Surgeon General. Rockville (MD): US Department 

of Health and Human Services, Public Health Service, 

Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health. 

DHHS Publication No. (CDC) 87-8398, 1986a. 

US Department of Health and Human Services. The 

Health Consequences of Using Smokeless Tobacco. Bethesda 

(MD): US Department of Health and Human Services, 

Public Health Service, National Institutes of Health. 

NIH Publication No. 86-2874, 1986b. 

US Department of Health and Human Services. The 

Health Consequences of Smoking: Nicotine Addiction. A 

Report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, Public Health 

Service, Centers for Disease Control, Center for Health 

Promotion and Education, Office on Smoking and 

Health. DHHS Publication No. (CDC) 88-8406, 1988. 

US Department of Health and Human Services. The 

International Classification of Diseases, Clinical Modification, Volume 1, 9th Revision. Rockville (MD): Department of Health and Human Services, Public Health 

Service, Health Care Financing Administration. DHHS 

Publication No. 89-1260, 1989a. 

202 Chapter 3 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of 

Progress. A Report of the Surgeon General. Atlanta: US 

Department of Health and Human Services, Public 

Health Service, Centers for Disease Control, Center for 

Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health. DHHS Publication No. 

(CDC) 89-8411, 1989b. 

US Department of Health and Human Services. The 

Health Benefits of Smoking Cessation. A Report of the Surgeon General. Atlanta: US Department of Health and 

Human Services, Public Health Service, Centers for 

Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and 

Health. DHHS Publication No. (CDC) 90-8416, 1990. 

US Department of Health and Human Services. Health 

Status of Minorities and Low-Income Groups. 3rd ed. 

Washington (DC): US Department of Health and Human Services, Public Health Service, Health Resources 

and Services Administration, Bureau of Health Professions, Division of Disadvantaged Assistance, 1991. 

US Department of Health and Human Services. Preventing Tobacco Use Among Young People. A Report of the 

Surgeon General. Atlanta: US Department of Health and 

Human Services, Public Health Service, Centers for 

Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health, 1994. 

US Department of Health, Education, and Welfare. 

Smoking and Health: Report of the Advisory Committee to 

the Surgeon General of the Public Health Service. Washington (DC): US Department of Health, Education, and 

Welfare, Public Health Service. PHS Publication No. 

1103, 1964. 

US Environmental Protection Agency. Respiratory 

Health Effects of Passive Smoking: Lung Cancer and Other 

Disorders. Washington (DC): US Environmental Protection Agency, Office of Research and Development, 

Office of Air and Radiation. EPA/600/5–90/006F, 1992. 

Valway S, editor. Cancer Mortality Among Native Americans in the United States: Regional Differences in Indian 

Health, 1984–1988 and Trends Over Time, 1986–1987. 

Rockville (MD): US Department of Health and Human 

Services, Public Health Service, Indian Health Service, 

Office of Health Programs, Division of Clinical and 

Preventive Services, Cancer Prevention and Control 

Program, 1992. 

Vander Martin RV, Cummings SR, Coates TJ. Ethnicity 

and smoking: differences in white, black, Hispanic, and 

Asian medical patients who smoke. American Journal 

of Preventive Medicine 1990;6(4):194–9. 

Vickers RR Jr, Conway TL, Hervig LK. Demonstration 

of replicable dimensions of health behaviors. Preventive Medicine 1990;19(4):377–401. 

Wagenknecht LE, Cutter GR, Haley NJ, Sidney S, 

Manolio TA, Hughes GH, et al. Racial differences in 

serum cotinine levels among smokers in the Coronary 

Artery Risk Development in (Young) Adults Study. 

American Journal of Public Health 1990;80(9):1053–6. 

Wagenknecht LE, Haley NJ, Jacobs DR Jr. Wagenknecht 

and colleagues respond [letter]. American Journal of 

Public Health 1992;82(8):1173. 

Wagenknecht LE, Manolio TA, Sidney S, Burke GL, 

Haley NJ. Environmental tobacco smoke exposure as 

determined by cotinine in black and white young 

adults: the CARDIA study. Environmental Research 

1993;63(1):39–46. 

Warburton DM. Psychopharmacological aspects of 

nicotine. In: Wonnacott S, Russell MAH, Stolerman IP, 

editors. Nicotine Psychopharmacology: Molecular, Cellular, and Behavioural Aspects. Oxford (England): Oxford 

University Press, 1990:77–111. 

Welty TK, Coulehan JL. Cardiovascular disease among 

American Indians and Alaska Natives. Diabetes Care 

1993;16(1 Suppl):277–83. 

Welty TK, Lee ET, Yeh J, Cowan LD, Go O, Fabsitz RR, 

et al. Cardiovascular disease risk factors in American 

Indians: the Strong Heart Study. American Journal of 

Epidemiology 1995;142(3):269–87. 

Welty TK, Zephier N, Schweigman K, Blake B, 

Leonardson G. Cancer risk factors in three Sioux tribes: 

use of the Indian-Specific Health Risk Approval for 

data collection and analysis. Alaska Medicine 1993; 

35(4):265–72. 

Wenneker MB, Epstein AM. Racial inequalities in the 

use of procedures for patients with ischemic heart disease in Massachusetts. Journal of the American Medical 

Association 1989;261(2):253–7. 

Health Consequences 203 
 

Surgeon General's Report 

Weston A, Caporaso NE, Perrin LS, Sugimura H, Tamai S, 

Krontiris TG, et al. Relationship of H-ras-1, L-myc, and 

p53 polymorphisms with lung cancer risk and prognosis. Environmental Health Perspectives 1992; 

98:61–7. 

Weston A, Vineis P, Caporaso NE, Krontiris TG, 

Lonergan JA, Sugimura H. Racial variation in the distribution of Ha-ras-1 alleles. Molecular Carcinogenesis 

1991;4(4):265–8. 

Whittle J, Conigliaro J, Good CB, Lofgren RP. Racial 

differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. New England Journal of Medicine 1993; 

329(9):621–7. 

Wiggins CL, Samet JM. Methods. In: Becker TM, 

Wiggins CL, Elliott RS, Key CR, Samet JM, editors. 

Racial and Ethnic Patterns of Mortality in New Mexico. 

1st ed. Albuquerque (NM): University of New Mexico 

Press, 1993:1–11. 

Wingard DL, Berkman LF, Brand RJ. A multivariate 

analysis of health-related practices. American Journal 

of Epidemiology 1982;116(5):765–75. 

Winkleby MA, Fortmann SP, Rockhill B. Health-related 

risk factors in a sample of Hispanics and whites 

matched on sociodemographic characteristics: the 

Stanford Five-City Project. American Journal of Epidemiology 1993;137(12):1365–75. 

Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, 

Fraumeni JF Jr. Snuff dipping and oral cancer among 

women in the southern United States. New England 

Journal of Medicine 1981;304(13):745–9. 

Wolfe MD, Carlos JP. Oral health effects of smokeless 

tobacco use in Navajo Indian adolescents. Community 

Dentistry and Oral Epidemiology 1987;15(4):230–5. 

Wolff CB, Portis M, Wolff H. Birth weight and smoking practices during pregnancy among MexicanAmerican women. Health Care for Women International 

1993;14(3):271–9. 

World Health Organization. Manual of the International 

Statistical Classification of Diseases, Injuries and Causes 

of Death. Vol. 1. Geneva: World Health Organization, 

1977. 

Worth RM, Kato H, Rhoads GG, Kagan A, Syme SL. 

Epidemiologic studies of coronary heart disease and 

stroke in Japanese men living in Japan, Hawaii and 

California: mortality. American Journal of Epidemiology 

1975;102(6):481–90. 

Wu X, Hsu TC, Spitz MR. Mutagen sensitivity exhibits a dose-response relationship in case-control studies. Cancer Epidemiology, Biomarkers & Prevention 

1996;5(7):577–8. 

Wu-Williams AH, Samet JM. Lung cancer and cigarette smoking. In: Samet JM, editor. Epidemiology of 

Lung Cancer. New York: Marcel Dekker, 1994:71–108. 

Yano K, MacLean CJ, Reed DM, Shimizu Y, Sasaki H, 

Kodama K, et al. A comparison of the 12-year mortality and predictive factors of coronary heart disease 

among Japanese men in Japan and Hawaii. American 

Journal of Epidemiology 1988;127(3):476–87. 

Yano K, Reed DM, McGee DL. Ten-year incidence of 

coronary heart disease in the Honolulu Heart Program. 

American Journal of Epidemiology 1984;119(5):653–66. 

Young TK. The Health of Native Americans: Toward a 

Biocultural Epidemiology. New York: Oxford University 

Press, 1994. 

Yu ESH. The health risks of Asian Americans [editorial]. American Journal of Public Health 1991;81(11): 

1391–2. 

Yu MC, Ross RK, Chan KK, Henderson BE, Skipper PL, 

Tannenbaum SR, et al. Glutathione s-transferase M1 

genotype affects aminobiphenyl-hemoglobin adduct 

levels in white, black, and Asian smokers and nonsmokers. Cancer Epidemiology, Biomarkers & Prevention 

1995;4(8):861–4. 

Yu MC, Skipper PL, Taghizadeh K, Tannenbaum SR, 

Chan KK, Henderson BE, et al. Acetylator phenotype, 

aminobiphenyl-hemoglobin adduct levels, and bladder cancer risk in white, black, and Asian men in Los 

Angeles, California. Journal of the National Cancer Institute 1994;86(9):712–6. 

Zane NWS, Takeuchi DT, Young KNJ. Confronting Critical Health Issues of Asian and Pacific Islander Americans. 

Thousand Oaks (CA): Sage Publications, 1994. 

204 Chapter 3 
Chapter 4
 

Factors That Influence Tobacco Use
 

Among Four Racial/Ethnic Minority Groups
 

Introduction 207
 

Historical Context of Tobacco 208
 

African Americans 208
 

American Indians and Alaska Natives 209
 

Asian Americans and Pacific Islanders 211
 

Hispanics 212
 

Economic Influences 213
 

Tobacco Industry Support for Racial/Ethnic Minority Communities 213
 

Employment Opportunities 213
 

Advertising Revenues 214
 

Funding of Community Agencies and Organizations 215
 

Support for Education 217
 

Support for Political, Civic, and Community Campaigns 217
 

Support for Cultural Activities 218
 

Support for Sports Events 219
 

Advertising and Promotion 220
 

Magazine Advertisements 221
 

Outdoor Advertisements 221
 

In-Store Promotions 222
 

Racial/Ethnic Symbols, Names, and Events 222
 

Targeted Products 223
 

Psychosocial Determinants 225
 

Initiation and Early Use of Tobacco 225
 

African Americans 226
 

American Indians and Alaska Natives 227
 

Asian Americans and Pacific Islanders 227
 

Hispanics 228
 

Multiple Group Studies 229
 

Prevalence of Risk Factors for Cigarette Use 229
 

Factors Associated with Initiation of Cigarette Use 231
 

Factors Associated with Initiation of Smokeless Tobacco Use 232
 

Summary, Initiation and Early Use of Tobacco 233
 

Tobacco Use Among Adults 233
 

African Americans 233
 

American Indians and Alaska Natives 233
 

Asian Americans and Pacific Islanders 234
 

Hispanics 234
 

Summary, Tobacco Use Among Adults 235
 
 

Smoking Cessation 235
 

African Americans 235
 

American Indians and Alaska Natives 237
 

Asian Americans and Pacific Islanders 237
 

Hispanics 237
 

Summary, Smoking Cessation 237
 

Methodological Limitations of the Literature 238
 

Chapter Summary 239
 

Conclusions 240
 

Appendix. A Brief History of Tobacco Advertising Targeting African Americans 240
 

Early Assumptions 240
 

Early Targeted Advertising Efforts (1940s–1960s) 241
 

Recent Targeted Advertising Efforts (Late 1960s–1980s) 243
 

References 245
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Introduction 

Tobacco use is determined and influenced by 

several kinds of factors: (1) individual factors (perceptions, self-image, peers); (2) social factors (societal 

norms); (3) environmental factors, such as advertising 

and economics; and (4) cultural factors, such as 

traditional uses of tobacco, acculturation, and the 

historical context of the tobacco industry in various 

communities. Behavior and patterns of tobacco use 

result from each of these factors and from their complex interplay, which is difficult to study and measure. 

Although available evidence has demonstrated that 

these factors contribute to behavior, research has been 

unable to quantify the distinct effect of each one and 

the effects of their interaction. The lack of definitive 

literature points to the need for further research to better quantify the ways in which a person’s exposure to 

various social, environmental, and cultural influences 

affects tobacco use behavior. Most likely, it is not a 

single factor but rather the convergence or interaction 

of some or all of these factors that significantly influences both a person’s decision to use tobacco and patterns of tobacco use (U.S. Department of Health and 

Human Services [USDHHS] 1989; Lynch and Bonnie 

1994; USDHHS 1994). This chapter examines the complex factors that influence tobacco use among the four 

major racial/ethnic minority groups. 

Tobacco has a role in all communities through 

social, economic, and cultural connections. These connections include (1) social customs, such as the sharing and giving of tobacco in Asian communities; (2) 

employment opportunities and economic growth 

provided to racial/ethnic groups through tobacco 

agriculture and manufacturing; (3) tobacco industry 

support of community leaders and organizations; (4) 

tobacco industry sponsorship of cultural events; and 

(5) ceremonial and medicinal uses of tobacco. Indeed, 

tobacco’s history has led to some positive social 

perceptions of tobacco, perceptions that may also 

influence use. 

Cigarette advertising and promotion may stimulate cigarette consumption by (1) encouraging children 

and adolescents to experiment with and initiate regular tobacco use, (2) deterring current tobacco users from 

quitting, (3) prompting former users to begin using 

again, and (4) increasing daily consumption by serving as an external cue to smoke (Centers for Disease 

Control [CDC] 1990a). Whether or not they are 

intended to do so, advertising and promotional activities appear to influence risk factors for adolescent 

tobacco use (USDHHS 1994). Cigarette advertising 

appears to affect young people’s perceptions of the pervasiveness, image, and function of smoking. Because 

misperceptions in these areas constitute psychosocial 

risk factors for the initiation of smoking, cigarette advertising appears to increase young people’s risk of 

smoking. The Food and Drug Administration (FDA) 

recently concluded that although advertising may not 

be the most important factor in a child’s decision to 

smoke, studies establish that it is a substantial contributing factor (Federal Register 1996). 

A different kind of influence is found in psychosocial variables, which help explain why people start 

using tobacco, why some continue using it, and why 

some stop using it. Published research findings are 

scant about individual and interpersonal factors that 

influence tobacco use among African Americans, 

American Indians, Alaska Natives, Asian Americans, 

Pacific Islanders, and Hispanics. This paucity of data, 

in fact, both inspired and hampered the development 

of this report. Although research findings based on 

samples of the majority white population may be 

applicable to racial/ethnic populations, such 

generalizability has not been sufficiently studied. 

Furthermore, cultural differences exist among communities and members of various racial/ethnic groups in 

values, norms, expectancies, attitudes, and the historical context of tobacco and the tobacco industry. Such 

differences, in turn, may influence both the prevalence 

of cigarette smoking in a particular racial/ethnic minority group and the effect of certain associated risk 

factors (Marín et al. 1990a; Vander Martin et al. 1990; 

Robinson et al. 1992a). 

Another important factor that may influence tobacco use behavior is the actual infrastructure within 

a community for conducting tobacco control activities 

that support a non-tobacco-use norm. This capacity 

of the community for tobacco control activities is also 

discussed in Chapter 5 of this report because it directly 

affects such programs, in addition to the influence it 

may have on the environmental context of tobacco use. 

The first part of this chapter summarizes the history of tobacco use among members of the four major 

racial/ethnic groups in the United States—African 

Americans, American Indians and Alaska Natives, 

Asian Americans and Pacific Islanders, and Hispanics. The association between the tobacco industry and 

these communities, including economic influences and 

the role of targeted advertising and promotion, is also 

Factors That Influence Tobacco Use 207 
 

Surgeon General’s Report 

described. The second part of the chapter discusses 

psychosocial influences associated with initiation of 

tobacco use, maintenance, and cessation among the 

four groups. Unfortunately, the limited information 

available affects the length and comprehensiveness of 

the presentation. The appendix presents a short hisHistorical Context of Tobacco 

tory of tobacco advertising targeting African Americans. Because so little information is available on the 

history of cigarette advertising aimed at American Indians, Alaska Natives, Asian Americans, Pacific Islanders, and Hispanics, these groups are not discussed in 

the appendix. 

African Americans 

The first recorded landing of Africans in the 

United States was in 1619, when a group of indentured 

servants was brought to Jamestown, Virginia (Foner 

1981), and Jamestown quickly became the center for 

profitable tobacco trade with England and other European nations (USDHHS 1992). Indeed, a significant 

portion of the early colonies’ wealth derived from the 

exportation of tobacco (Northrup and Ash 1970). Cotton did not become preeminent until the invention of 

the cotton gin in 1793 (Foner 1981). Tobacco farming 

was widespread throughout the south, and although 

tobacco was later supplanted by other crops (including cotton) in many areas, it remains a major crop in 

six states—Georgia, Kentucky, North Carolina, South 

Carolina, Tennessee, and Virginia (Gale 1993). 

Whites initially were employed in tobacco cultivation, but as tobacco prices fell in Europe, tobacco 

companies began using less expensive labor (Kulikoff 

1986). Among other factors, the need for a larger and 

less expensive labor force to grow tobacco led the colonies to gradually transform the status of Africans from 

indentured servants, who earned their freedom after 

a period of involuntary servitude, to slaves, who were 

the property of their masters for life. In addition to 

slaves, many free African Americans worked in tobacco farming during the 18th and 19th centuries. Indeed, more free African Americans were employed in 

tobacco production than in any other occupational 

category in the south during that time (Northrup and 

Ash 1970). Slaves also hired themselves out as tobacco 

laborers, and some earned enough funds to purchase 

their freedom. 

After emancipation, freed African Americans 

who had obtained some acreage began farming tobacco because it was a cash crop that did not require 

much land to be profitable. In particular, freed 

African Americans farmed tobacco in Georgia, North 

Carolina, South Carolina, and Virginia. Nevertheless, 

the number of tobacco farms owned by African Americans has declined dramatically in the 20th century, possibly because so many African Americans, including 

tobacco farm owners and laborers, were migrating to 

the north (U.S. Commission on Civil Rights 1982; Gale 

1993). 

In the colonial period and early years of the 

United States, African Americans and whites worked 

side by side in cigarette-manufacturing factories, 

which tended to be primarily small cottage industries. 

However, the introduction of the cigarette-making 

machine in the mid-1880s changed this pattern. Because white women were viewed as the only group 

that had the manual dexterity needed to operate the 

machines, and it was socially unacceptable for African American men and women to work alongside 

white women, African Americans were replaced as 

factory workers and relegated to less skilled, menial, 

field jobs (Northrup and Ash 1970; Meyer 1992). During the early 1900s, the dirtiest, unhealthiest, and lowest paying jobs in tobacco factories were carried out 

by African American women (Jones 1984). Because 

the jobs held by African Americans in stemming and 

processing the tobacco leaf were low paying, the tobacco industry made little effort to mechanize such jobs 

before the early 1930s. Thus, many African Americans 

remained employed in the tobacco industry, even as 

tobacco factories began replacing people with laborsaving machines (Northrup and Ash 1970). 

The high concentration of African Americans in 

certain occupations helped them gain a foothold in one 

of the few areas in which organized labor had achieved 

success in the south. Initial unionizing efforts by the 

Tobacco Workers International Union began in the 

early 20th century (Kaufman 1986). The efforts of the 

United Tobacco Workers Local 22 to encourage African American members to register for and vote in 

municipal elections are credited with the election of 

an African American to the city council of WinstonSalem, North Carolina, in 1947. At the same time, a 

208 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

rival—the Food, Tobacco, Agriculture, and Allied 

Workers Union—sought to involve African Americans 

in its unionizing efforts as equals. United Tobacco 

Workers Local 22, which represented workers at the 

R.J. Reynolds Tobacco Company in Winston-Salem, 

remained one of the strongest unions in the south. The 

union represented equal numbers of African American and white workers. In addition, African American women held significant leadership roles in the 

union (Lerner 1973; Foner 1981). This early unionization among African Americans in tobacco-producing 

states was of such historic importance that it is considered one of the first civil rights movements (Korstad 

and Lichtenstein 1988). Probably as a result of the racial divisions within the union movement and the residual power held by African American workers, R.J. 

Reynolds was the first company to have African Americans operate cigarette-making machines after World 

War II and, in 1961, to open a factory with integrated 

production lines and desegregated facilities (Northrup 

and Ash 1970). 

Nevertheless, tobacco cultivation has not contributed significantly to the economic well-being of African Americans in the southern states. In each of 

the decennial censuses conducted between 1960 and 

1990, about one-third of all counties in the south where 

tobacco is a major agricultural product have been identified as areas of persistent poverty. These povertystricken counties—concentrated in Georgia, North 

Carolina, and South Carolina—tend to have more 

farms owned and operated by African Americans than 

the south in general (Gale 1993). In addition, economies of scale and the increasing mechanization of tobacco growing have accelerated the decrease in tobacco 

farming, particularly by African Americans (U.S. Commission on Civil Rights 1982; Gale 1993). For example, 

by 1987, more than 50 percent of the farms operated 

by African Americans specialized in livestock production, and only 11 percent specialized in tobacco growing (Gale 1993). 

In summary, tobacco has been a part of the experience of African Americans since the early 1600s, when 

Africans were first brought to the Americas. The relationship between African Americans and tobacco 

growers and manufacturers has changed in the 

postslavery era but remains strong and complex, particularly since the mid-1940s. The strength derives 

from the important economic role of tobacco among 

African Americans, and the complexity comes from 

the contradictory social and economic forces that 

affected the African American worker. In addition, 

changing market forces helped make African Americans significant users of tobacco. As a result, the relationship of African Americans to the tobacco industry 

was no longer primarily dependent on their role as 

workers in the tobacco labor force but was now influenced as well by their status as consumers. For example, until the mid-1940s, many African Americans 

held low-paying jobs in tobacco-related agriculture 

and industry; around the time of World War II, however, some tobacco companies began to advertise to 

African Americans. Advertising efforts increased in 

the 1950s, a decade that saw African American men 

surpass white men in smoking prevalence. During this 

same time, the tobacco industry was hiring and promoting African American workers. Other influences 

affecting African Americans’ ties to tobacco were the 

tobacco industry’s increased attention to and positive 

steps toward civil rights in the 1950s and 1960s, the 

broadcast ban on tobacco advertising that led the tobacco industry to seek more targeted market segments 

in the 1970s, and the expansion of African American 

political power in the 1980s and 1990s, which served 

to give the tobacco industry additional access to the 

African American community (Robinson et al. 1992b). 

The historical patterns underpinning the African 

American community’s relationship to tobacco may 

affect African Americans’ attitudes and behaviors towards tobacco. 

American Indians and Alaska Natives 

Tobacco has long played an important role in 

the cultural and spiritual life of North and South 

American Indians and Alaska Natives. When the Europeans colonized the Americas, tobacco already was 

being cultivated and used in many parts of the continent. Early European explorers documented the 

cultivation and farming of tobacco and its extensive 

use among tribes throughout most of North and South 

America (Hodge 1910; Linton 1924) and in Alaska’s 

interior (Sherman 1972)—findings that have been supported by archaeological discoveries at a variety of sites 

(Haberman 1984). 

When Europeans first arrived in the Americas, 

tobacco served various purposes among American 

Indians and Alaska Natives, including ceremonial, religious, and medicinal functions (McCullen 1967; Seig 

1971; Ethridge 1978). In ceremonial and religious rites, 

tobacco was a significant part of sacramental offerings. 

For example, tobacco was used to ensure good luck in 

hunting and to seal peace and friendship agreements. 

When used for medicinal purposes, tobacco often was 

mixed with other substances in topical ointments and 

ingested for internal healing. For example, in the 

Factors That Influence Tobacco Use 209 
 

Surgeon General’s Report 

northwest region of North America, tobacco was combined with shell lime powder and then formed into 

small marble-sized balls that were dissolved in the 

mouth (Linton 1924). Tobacco smoke often was used 

during prayers to aid in healing and was prescribed 

to cleanse people, places, and objects of unwanted spirits. Tobacco smoke also was used at the beginning of 

meetings as a ritual to cleanse the room and secure the 

truth from the spoken word. 

Early inhabitants of the American continent also 

inhaled tobacco smoke (Linton 1924). They often 

placed burning or smoldering tobacco on the bare 

ground or on a mound and then waved the smoke toward their faces using the palms of their hands. Early 

inhabitants also smoked rolled sheets of dried tobacco 

leaves (cigars) and wrappings of cut tobacco, and they 

smoked tobacco through a flaxen reed. The most common way to smoke tobacco was to place cut tobacco 

within the bowl of a calumet—either a stone or a 

hollowed-out bone pipe (Linton 1924). 

Tobacco smoking was part of many solemn occasions among American Indians, such as when leaders met (Paper 1988). In some tribes, the pipe became 

such a powerful object that it was considered sacred. 

Only certain individuals could use the pipe, and only 

sacredly gathered tobacco could be burned in a pipe’s 

bowl (Linton 1924). The Hopi Tribe used tobacco religiously, blowing smoke in the four sacred directions 

to invoke good planting and to encourage rainfall. 

Other tribes, such as the Delaware, Iroquois, and Sioux, 

smoked tobacco during prayers, at the opening of the 

sacred bundle—a collection of religious artifacts (Paper 

1988). Tobacco also was used between enemies in 

battle to signify a truce. If one party offered the pipe 

and the other party accepted it, this signified the end 

of the battle, and both parties would then put down 

their weapons. As a result, the smoking of tobacco 

leaves, often with the peace pipe, became associated 

with the American Indian as a common symbol 

that had significant positive social and cultural 

connotations. 

During the 1700s, tobacco became one of the most 

important commodities traded among American Indians and Alaska Natives. For example, Alaska Natives in the Arctic and sub-Arctic regions depended 

on trade with tribes from the east and south of the 

North American continent to obtain tobacco products 

(Fortuine 1989). Among the items traded were special 

smoking vessels, such as pipes made of stone quarried in what is now Wisconsin and Minnesota (Linton 

1924; Paper 1988). 

With the European colonization of the American 

continent, tobacco became known in Europe, where it 

was at times expressly forbidden, primarily because 

of health concerns about the dangers of tobacco spitting. Following tobacco practices in the Americas, 

early European explorers smoked tobacco the way it 

was smoked by American Indians (Linton 1924). Indeed, many of the pipes these explorers used were 

fashioned after tribal pipes. Europeans also adopted 

many of the tribes’ medicinal uses of tobacco. However, the use of tobacco for recreational purposes was 

widely accepted and soon became primary. Europeans also began to chew tobacco raw rather than in a 

mixture of powdered shells or roots, as was the custom of North American tribes. 

Most early American Indian tobacco harvesting 

was done with farming technologies that originated 

in the Southern part of North America (Paper 1988). 

For example, nonfarming nomadic tribes and light 

farming tribes scattered tobacco seeds on holy grounds 

near waterways or marshes and let the plants grow 

without much cultivation. In fact, the Iroquois prohibited their people from cultivating tobacco plants 

or coming in contact with them while the plants were 

growing to maturity. Other tribes, such as the 

Blackfeet, Crow, and some Northern Plains Indian 

people, grew tobacco plants instead of food crops in 

small sacred patches for medicinal and ceremonial uses 

(Linton 1924). 

Over the centuries as American Indians and 

Alaska Natives experienced vast cultural and political 

upheaval, their attitudes about tobacco changed significantly. Today, among some contemporary American Indian and Alaska Native groups, tobacco use has 

lost some of its traditional attributes and no longer is 

endowed with the same special meaning. However, 

some American Indians have maintained the traditional 

practices associated with tobacco. For example, tobacco 

is given as a gift to traditional healers and dancers at 

powwows and many other social gatherings, and it is 

presented to honor persons celebrating important 

events, such as marriages. Many American Indians 

consider tobacco to be a medicine that can improve their 

health and assist in spiritual growth when used in a 

sacred and respectful manner. It is important to recognize the positive social context in which tobacco is 

viewed in American Indian communities and to recognize the difficulties these connotations may cause in 

preventing tobacco use among youth and helping 

adults to quit. It is possible that tobacco control efforts 

could be enhanced by emphasizing the distinction between sacred uses of tobacco on ceremonial occasions 

and addictive tobacco use by individuals. An additional 

complicating factor for tobacco control efforts among 

this population is that American Indians have become 

210 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

increasingly reliant on tobacco sales and on the 

revenues these sales bring to the reservations (see 

Tobacco Industry Support for Racial/Ethnic Minority 

Communities later in this chapter). 

Asian Americans and Pacific Islanders 

Because about 63 percent of the Asian Americans 

and Pacific Islanders in the United States are immigrants (U.S. Bureau of the Census 1993), their lives have 

been influenced by the history of tobacco use in Asia 

and the Asian Pacific. Asia’s many countries and cultures have different traditions regarding the use of tobacco. These differences are also reflected in Asian 

Americans and Pacific Islanders themselves. Tobacco 

was introduced in Asia in the early 17th century by 

Europeans (Goodman 1992). Like the introduction of 

opium in China, the exportation of tobacco to Asia has 

led to an addiction that has dramatically changed the 

health behaviors of Asians (Chen and Winder 1990). 

The Dutch brought tobacco to China, where it was 

mixed with opium. The Chinese subsequently introduced tobacco in Mongolia, Tibet, and Eastern Siberia 

(Goodman 1992). Early Portuguese explorers then 

carried tobacco to India, Japan, and Java in 1605, and 

the Japanese in turn introduced tobacco in Korea 

(Laufer 1924). Asians later used tobacco in ways more 

similar to its medicinal uses in other parts of the world. 

In China, for example, tobacco was used as a remedy 

against colds, malaria, and cholera. The beliefs about 

the usefulness of tobacco as a medicine were so ingrained in China during the 17th century that two 

imperial edicts (1638 and 1641) prohibiting its use 

failed to curtail tobacco use. 

Currently, tobacco is a crop of great significance 

in Asia. In 1990, Asian countries produced approximately 60 percent of the world’s tobacco crop 

(Goodman 1992). By 1995, United Nations statistics 

showed that Asian countries were producing 63.2 percent of tobacco leaves in the world (Food and Agriculture Organization of the United Nations [FAO] 1996). 

Both China (34.1 percent) and India (9.0 percent) 

ranked above the United States (6.3 percent) in the 

percentage of total tobacco leaf production (FAO 1996). 

In China, the manufacture and sale of tobacco products are part of the economic role that tobacco plays. 

After foreign investment was legalized in China in 

1979, the China National Tobacco Corporation entered 

into joint ventures with Philip Morris, R.J. Reynolds, 

and other foreign tobacco companies. The China National Tobacco Corporation has dramatically increased 

production after implementing western technology, 

and its 183 cigarette factories, 150 tobacco drying 

plants, 30 research institutes, and 520,000 workers 

make up a strong part of the local economy (Frankel 

and Mufson 1996). 

Whereas cigars, pipes, snuff, chewing tobacco, 

cheroots (cigars), bidis (cigarettes of India), and kreteks 

(clove cigarettes) initially were more commonly used 

than regular tobacco cigarettes in Asia, cigarettes now 

are an integral part of contemporary Asian and Asian 

Pacific life. As expected, Asians and Pacific Islanders 

who migrate to the United States bring with them the 

attitudes and expectancies that have characterized the 

use of tobacco in their countries of origin. Sharing cigarettes, particularly among adult male guests, is a gesture of hospitality in a number of Asian cultures (Tamir 

and Cachola 1994). For example, distributing cigarettes, particularly U.S. cigarettes, at Cambodian weddings is a customary way of honoring the bride and 

groom. In China, foreign visitors are expected to give 

cartons of cigarettes to their hosts. In this regard, the 

importance of using tobacco as a form of social exchange is very similar to the reinforcement given to 

tobacco use among Hispanics. 

Cigarette smoking also has acquired utilitarian 

uses in some Asian countries. In Southeast Asia, for 

example, cigarette smoking is perceived as a way to 

keep warm at night and to keep mosquitoes away 

(Mackay and Bounxouie 1994). In some provinces in 

China, anecdotal information indicates that babies and 

toddlers are given puffs of lighted cigarettes to stop 

them from crying (Mackay et al. 1993). 

Cigarette smoking in Asian society has been 

popularly associated with affluence and sophistication 

(Frankel and Mufson 1996). Accordingly, the promotion of cigarette smoking in Asian countries follows 

patterns fairly similar to those found in the United 

States, where cigarette smoking is glamorized and often associated with affluence. In a recent article, Sesser 

(1993) recounted how in one week of traveling in Asia 

he “attended a Virginia Slims fashion show at a Taiwanese disco, watched the finals of the Salem Open 

tennis tournament in Hong Kong, and followed the 

progress of the Marlboro Tour ’93, a bicycle race in the 

Philippines” (p.78). Cigarettes made in the United 

States are not only promoted in those Asian countries 

where the importation of foreign cigarettes is allowed, 

but also in China, where U.S. cigarettes are not freely 

sold (Stebbins 1990). In these cases, brand recognition 

is an important outcome of promotional campaigns 

once the market is opened to imported cigarettes. 

Before market access trade actions by the United 

States in the 1980s, advertising was unnecessary in 

most Asian countries because tobacco production was 

operated through state-owned tobacco monopolies. 

Factors That Influence Tobacco Use 211 
 

Surgeon General’s Report 

As a result, few brands were available for purchase. 

The expansion of large transnational corporations 

(e.g., British American Tobacco Company, Ltd., and 

Philip Morris Companies Inc.) into Asian markets 

brought about more brand competition and, thus, more 

advertising. Advertising techniques have included 

sponsorship of rock concerts and teen dances and extensive radio and outdoor advertising (Frankel and 

Mufson 1996). According to a study reported by the 

National Bureau of Economic Research using data from 

Japan, Taiwan, South Korea, and Thailand, “. . . in 1991, 

average per capita cigarette consumption was nearly 

ten percent higher than it would have been had the 

markets remained closed to U.S. cigarettes” 

(Chaloupka and Laixuthai 1996, p. 13). 

The paucity of information about tobacco use 

among Asian Americans and Pacific Islanders hampers the formation of substantive conclusions about 

the relationship between community attitudes and 

behaviors and the historical relationship with tobacco 

and the tobacco industry. Existing information, however, is sufficient to show that factors associated both 

with the respective native cultures and with acculturation are important. Tobacco prevention and control 

programs must take these cultural factors into account 

to positively influence the norms, attitudes, and behaviors of these racial/ethnic communities. 

Hispanics 

The cultivation and processing of tobacco have 

played a significant role in the economies of most Latin 

American countries, including Brazil (Nardi 1985), 

Colombia (De Montaña 1978), Cuba (Rivero Muñiz 

1964), and Mexico (Ros Torres 1984). In 1995, the level 

of production of tobacco leaf in South America alone 

reached 9.1 percent of the world total (FAO 1996). 

In the United States, Hispanics, primarily those of 

Cuban ancestry, have played a key role in the manufacture of cigars in Florida factories. As is true of all 

immigrants, Hispanics who migrate from Latin 

America are influenced by historical conditions in their 

native countries regarding tobacco and the tobacco 

industry and bring with them the attitudes and expectancies that characterize tobacco use in their countries of origin. These attitudes and expectancies are 

often modified as the process of acculturation takes 

place (Marín et al. 1989a). 

The history of tobacco use in Central and South 

America as well as in the Caribbean predates the arrival of the European explorers and therefore has acquired a rich lore. Tobacco played a prominent role in 

religious and healing practices of native inhabitants 

of those regions. It was used by shamans or spiritual 

leaders to induce trancelike states, ensure fertility, and 

facilitate spiritual consultations. Many cultural and 

social norms surrounded tobacco, all of which have 

contributed to defining the role of tobacco in these 

societies. Tobacco became a staple crop of the Americas when the predominant means of obtaining food 

shifted from hunting to agriculture. Tobacco manufacture and trade played a significant role in the economies of the Caribbean, Latin America, and North 

America. A detailed account of the history of tobacco 

in the Americas can be found in the Surgeon General’s 

report Smoking and Health in the Americas (USDHHS 

1992). 

Recent surveys also indicate that Hispanic cigarette smokers have group-specific expectancies and 

attitudes that differentiate them from smokers of other 

racial/ethnic groups. These expectancies and attitudes 

are the product of social conditions and norms that 

have dictated the use of tobacco in Latin American 

countries for the last few centuries and are also the 

effects of certain relevant cultural values, such as 

simpatía (a social mandate for positive social relations), 

personalismo (the value placed on personal relationships), and familialism (the normative and behavioral 

influence of relatives) (Marín and Marín 1991). Among 

many Hispanics in the United States, cigarette smoking is a social activity (Marín et al. 1989a; 1990a,b). 

Although tobacco use remains a social activity among 

all communities, given the cultural values of simpatía 

and personalismo, sharing cigarettes often serves as a 

particularly strong form of social affiliation and friendship. This norm must often be considered when tobacco prevention and control programs are initiated 

within Hispanic communities. 

212 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Economic Influences 

Tobacco Industry Support for Racial/Ethnic 

Minority Communities 

The tobacco industry’s longtime economic 

support for U.S. racial/ethnic communities may have 

contributed to the survival of many of these communities’ institutions (Robinson et al. 1992b). For 

example, the tobacco industry supports African American communities in five main ways: (1) direct employment of African Americans, (2) support for social 

services and civil rights organizations, (3) contributions 

to politicians and political organizations, (4) support 

for educational and cultural programs, and (5) contracts with small businesses (Blum 1989; Robinson et 

al. 1992a,b). More recently, the tobacco industry also 

has provided economic support to American Indian, 

Alaska Native, Asian American, Pacific Islander, and 

Hispanic communities. 

As detailed below, the tobacco industry has employed members of racial/ethnic communities primarily in farming and manufacturing, although some 

have been employed in sales and marketing positions. 

The industry’s support for social services and civil 

rights organizations and its involvement in educational 

and cultural activities have been wide-ranging. This 

support has included contributions to endowments, 

scholarship funds, and literacy campaigns as well as 

support for artistic groups, exhibits, and performances. 

Contributions from tobacco companies and tobaccorelated political action committees have underwritten 

the growth of racial/ethnic political power at the 

local, state, and national levels. In addition, many tobacco companies use the services of minority-owned 

businesses either through their own internal programs 

or through formal alliances with such groups as Operation PUSH (People United to Save Humanity) and 

the National Association for the Advancement of Colored People (NAACP). In addition, tobacco product 

sales and promotions have contributed to the economies of racial/ethnic communities. For example, the 

sale of cigarettes and smokeless tobacco contributes 

to the economies of small corner convenience stores 

catering to racial/ethnic minority communities in urban areas. Tobacco is an important income-generating 

resource also on some Indian reservations. Because 

reservations are exempt from paying excise and sales 

taxes on tobacco products, tobacco shops are operated 

to produce additional income for the community. Although these shops are legally restricted to selling 

tax-free cigarettes to American Indians, this restriction 

is rarely monitored. A number of reservations are 

located a short distance from major cities whose residents often drive to the reservations to purchase taxfree or low-tax cigarettes and other tobacco products. 

The interrelationships between the tobacco industry and racial/ethnic group leaders, industries, and 

community agencies may have served to strengthen 

bonds between the industry and the four racial/ethnic groups that are the subject of this report. These 

relationships are based on several factors, one being 

that the tobacco industry has often been the only source 

of funds for community initiatives. In addition, the 

tobacco industry has built personal alliances with 

members of racial/ethnic groups through employment 

and personal relationships (Robinson et al. 1992b). 

Indeed, Philip Morris’s record in making financial commitments to community programs as a result of 

racial/ethnic-related networking has been noted 

(Stanley 1996). Efforts in African American communities to put tobacco control strategies in place have 

had to overcome some leaders and organizations who 

were reticent about such action because the community had a positive relationship with the tobacco industry, partly based on the industry’s strong support 

for local economic, social, and cultural activities 

(Robinson et al. 1992b). Many leaders and members 

of these communities have a positive predisposition 

toward both the industry and cigarette smoking. 

Employment Opportunities 

Although the tobacco industry initially discriminated against African Americans, excluding them from 

many types of factory jobs, it eventually began hiring 

many African Americans in manufacturing positions 

(Northrup and Ash 1970). By the 1930s, African Americans made up about half of all persons employed in 

the process of taking tobacco from its leafy state to a 

finished product (Northrup and Ash 1970; Foner 1981). 

African Americans have been concentrated in the 

tobacco industry for three main reasons: (1) factories 

were located in the Southern states, where the African 

American population was largest; (2) more laborers 

were needed as the demand for cigarettes grew after 

World War I; and (3) other opportunities opened for 

whites in an expanding economy, leaving African 

Americans with few job alternatives because of racial 

Factors That Influence Tobacco Use 213 
 

Surgeon General’s Report 

discrimination and other factors (Northrup and Ash 

1970). 

In the last few decades, the involvement of African Americans in the production and marketing of 

tobacco has changed significantly. By 1960, African 

Americans represented less than 25 percent of tobacco 

workers—a decline from more than 50 percent 30 years 

earlier. Possible reasons for this dramatic decrease 

include (1) the migration of African Americans from 

southern to northern states; (2) the imposition of the 

minimum wage, which eliminated many of the lowpaying jobs in which African Americans were concentrated; (3) the mechanization of tobacco factories, 

which required fewer people to produce the same 

number of cigarettes; and (4) the inability of unions to 

change the poor working conditions of African American workers, leading to their exodus from those companies (Northrup and Ash 1970). 

Today, the tobacco industry employs African 

Americans as well as members of other racial/ethnic 

minority groups in a variety of factory, marketing, and 

promotional positions. In the latter two types of positions, members of racial/ethnic groups conduct promotional and marketing activities with owners of local 

shops and convenience stores serving racial/ethnic 

neighborhoods in urban areas and racial/ethnic enclaves in metropolitan areas. 

The tobacco industry was one of the early leaders among corporations in providing opportunities in 

management to qualified African Americans. Two 

African American executives of tobacco companies 

were honored in 1997 by the Business Policy Review 

Council at its annual Corporate Pioneers Gala Tribute 

for their long-term contributions as corporate pioneers 

in breaking down color barriers in the business world 

(US Newswire, Inc. 1997). 

Members of various racial/ethnic communities 

also have been employed as models or spokespersons 

in the advertising and promotion of tobacco products. 

Advertising and public relations agencies select racial/ 

ethnic minority models and celebrities to promote and 

advertise tobacco products to targeted racial/ethnic 

groups in print and outdoor advertisements. These 

easily recognizable racial/ethnic models and celebrities are essential to targeted advertising, and advertising agencies have relied heavily on members of racial/ 

ethnic communities to fill these modeling jobs. For 

example, the tobacco industry used African American 

athletes extensively to advertise tobacco products during the 1950s and 1960s, when racial integration was 

taking place in sports (see the appendix). In a study 

of advertising in Ebony magazine during the 1950s and 

1960s, investigators found that African American athletes were used in cigarette advertisements far more 

frequently than other African American celebrities and 

entertainers (Pollay et al. 1992). The use of well-known 

athletes, entertainers, and public figures in tobacco industry marketing and public relations campaigns has 

continued into the 1990s. 

Advertising Revenues 

By placing advertisements in racial/ethnic publications, primarily those with limited circulations, 

tobacco companies have become important contributors of advertising revenues for these publications 

(Blum 1986). As a result, many racial/ethnic minority 

publications—including community-oriented newspapers and national magazines—rely on revenues from 

tobacco advertising (Cooper and Simmons 1985; 

Milligan 1987; Blum 1989; Tuckson 1989; Robinson et 

al. 1992b). Some racial/ethnic publications independently sought closer economic ties with the tobacco 

industry. For example, after the ban on the broadcast 

advertising of tobacco products took effect in 1971, a 

group of African American newspaper publishers approached the tobacco companies and asked them to increase their business with African American media 

(Williams 1986). 

Corporate media leaders are aware of the reliance of African American publications on tobacco 

advertising (Robinson 1992). The publisher of Target 

Market News, an African American consumermarketing publication, has suggested that “reducing 

cigarette ads could deprive the inner city of muchneeded revenues” (Johnson 1992b, p. 27). Similarly, 

the president of an African American advertising 

agency has predicted that “if they kill off cigarette and 

alcohol advertising, black papers may as well stop 

printing” (Johnson 1992b, p. 27). In 1988, the National 

Black Monitor, a monthly insert in about 80 African 

American newspapers, published a three-part tribute 

to the tobacco industry. The National Black Monitor has 

defended its relationship with the tobacco industry and 

has stated that “black newspapers . . . could not have 

survived without the past and continuing support 

from the tobacco industry” (1990, p. 4). 

National and local publications directed at other 

racial/ethnic groups also frequently carry tobacco 

product advertisements and promotions. These include 

full-page, four-color advertisements in magazines and 

full-page advertising spreads in community newspapers. In 1989, for example, Hispanic magazine ran a short 

story contest, sponsored by Philip Morris, which offered 

a $1,000 honorarium and publication of the winning 

story. The contest was promoted in a special issue celebrating Hispanic Heritage Month, and announcements 

214 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

appeared in a message from the editor on the magazine’s 

first page and in a one-page display. 

The relatively high level of tobacco product advertisements in racial/ethnic and general publications 

is problematic because the editors and publishers may 

limit stories dealing with the damaging effects of tobacco or limit the level of antitobacco information in 

their publications for fear of retribution from tobacco 

companies (Evans 1990; Robinson et al. 1992a; Warner 

et al. 1992). Their concerns may be valid. For example, 

when Newsweek published an article on the nonsmokers’ rights movement, tobacco advertisers removed all 

tobacco advertisements from that issue and ran them 

later (Warner 1985). In addition, a study of cancer coverage and tobacco advertising over a six-year period 

in three African American popular magazines (Ebony, 

Essence, and Jet) found that these magazines published 

only nine articles that focused on cancers caused by 

cigarette smoking (six on lung or bronchus cancer, one 

on bladder cancer, and two on throat cancer). In the 

articles on lung cancer, smoking was rarely discussed 

as a major contributing cause; smoking was not mentioned as a cause of throat cancer (Hoffman-Goetz et 

al. 1997). 

Although magazines and newspapers with large 

circulations can sustain the sporadic loss of advertising revenues, the livelihood of racial/ethnic publications can be effectively threatened by such losses. 

Tobacco companies typically place less than 10 percent of their advertising budgets with small African 

American weeklies (Russ 1993); however, these advertisements may often mean the difference between survival and failure for small publications (Tuckson 1989; 

Robinson et al. 1992b). Magazine advertisements of 

tobacco products have decreased recently in all types 

of publications (Federal Trade Commission [FTC] 

1997), indicating that magazines distributed nationally, including those serving racial/ethnic minority 

communities, may rely somewhat less on tobacco 

companies for advertising revenues. For example, 6.5 

percent of Ebony’s full-page advertisements were for 

tobacco products in 1993, compared with 9.4 percent 

in 1988, 13.5 percent in 1983, and 11.6 percent in 1978 

(Gerardo Marín and Raymond Gamba, unpublished 

data). Additionally, a comparison of revenues generated from advertising for the first 11 months of 1989 

showed that major African American publications such 

as Jet, Ebony, and Essence received proportionately 

higher revenues from tobacco companies than did 

major mainstream publications (Ramirez 1990). 

Industries associated with the tobacco industry 

may also provide public relations support to racial/ 

ethnic publications. In 1992, for instance, an advertisement in Ebony paid for by the Nabisco Foods Group 

(RJR Nabisco, Inc., of which R.J. Reynolds Tobacco 

Company is a subsidiary) saluted the magazine’s 

publisher and seven other African American entrepreneurs as “role models to our nation’s youth and as 

inspiration to all of us” (Nabisco Foods Group 1992, 

p. 2). 

Eight-sheet billboards are also frequently used 

to advertise tobacco products in racial/ethnic communities. These billboards are small (5 x 11 feet) and are 

often placed close to eye level on the sides of buildings and stores. In 1985 alone, tobacco companies 

spent $5.8 million on eight-sheet billboards in African 

American communities; this amount accounted for 37 

percent of total expenditures for this medium. Tobacco 

companies spent $1.4 million on such billboards in 

Hispanic neighborhoods (Davis 1987). 

Funding of Community Agencies and 

Organizations 

The tobacco product and alcoholic beverage industries have made significant financial and in-kind 

contributions to various racial/ethnic community organizations at the local, regional, and national levels. 

These contributions have at times been described as 

marriages of convenience in which community organizations and agencies receive much-needed income 

and tobacco companies gain, at a minimum, name recognition and goodwill (Maxwell and Jacobson 1989). 

Trade publications suggest that such community relations efforts are “effective . . . devices to augment minority advertising efforts and throw some water on 

any hot spots” (DiGiacomo 1990, p. 32). Recipients of 

tobacco industry support include most of the larger 

national organizations as well as a plethora of smaller 

local community agencies. In fiscal year 1989, for example, organizations receiving support from tobacco 

companies included the Congressional Hispanic Caucus, the National Black Caucus of State Legislators, the 

National Urban League, and the United Negro College Fund (UNCF) (Johnson 1992a,b). Internal tobacco 

industry documents released by Doctors Ought to Care 

(DOC) show that Philip Morris gave more than $17 

million to racial/ethnic, educational, and arts groups 

in 1991 (Solberg and Blum 1992). 

One large racial/ethnic minority organization 

that has refused the support of the tobacco industry is 

the National Coalition of Hispanic Health and Human 

Services Organizations (COSSMHO), which has 

adopted a formal policy not to accept money from tobacco companies or their subsidiaries. The diversity 

Factors That Influence Tobacco Use 215 
 

Surgeon General’s Report 

of contributions to racial/ethnic community agencies 

can be illustrated through a review of contributions 

made to African American organizations. For example, 

Philip Morris has contributed to such organizations 

as the Leadership Conference on Civil Rights, the National Association of Black Social Workers, the National 

Association of Negro Business and Professional 

Women’s Clubs, the National Black Police Association, 

100 Black Men of America, Inc., the National Coalition of 100 Black Women, the National Conference of 

Black Lawyers, the National Minority AIDS Council, 

and Operation PUSH (Jackson 1992; Rosenblatt 1994). 

R.J. Reynolds has contributed to the NAACP; UNCF; 

and Opportunities Industrialization Centers of 

America, a national network of job training centers 

(Russ 1993). Other tobacco companies and the Tobacco 

Institute itself have made similar contributions to 

African American and Hispanic organizations 

(Robinson et al. 1992a). 

In communities where tobacco companies have 

offices and factories, additional programs and activities have been funded to the benefit of whites as well 

as members of racial/ethnic communities. This support has ranged from funding for local sites of the 

Young Men’s Christian Association to sponsorship of 

Christmas tree-lighting ceremonies (Jackson 1992). The 

tobacco industry also has participated in special celebrations and has sponsored awards and recognition 

events for various civic organizations. For example, 

at each year’s conference of the National Urban 

League, Philip Morris presents the Herbert H. Wright 

Awards to African American executives of major corporations who have excelled in working on behalf of 

humanitarian causes. The awards are named in 

memory of one of the first African American executives at Philip Morris. 

Promotional materials further document the tobacco industry’s involvement with racial/ethnic communities. Current information is difficult to obtain, 

but in 1986, RJR Nabisco published the booklet called 

A Growing Presence in the Mainstream, which summarized the company’s involvement with racial/ethnic 

communities amid quotations from Martin Luther 

King, Jr., John F. Kennedy, Booker T. Washington, Maya 

Angelou, and the New Testament, along with photographs of an African American member of the 

company’s board of directors (RJR Nabisco, Inc. 1986). 

The booklet reported a number of the company’s accomplishments, including RJR Nabisco’s record for 

employing members of racial/ethnic minority groups, 

the provision of more than 25 percent of RJR Nabisco’s 

total company-paid employee group life insurance 

by African American-owned insurance firms, the 

advertising of RJR Nabisco’s products in more than 

200 racial/ethnic magazines and newspapers each 

year, and recognition by the UNCF as the largest contributor to the fund’s schools since 1983. The booklet 

also listed 122 different organizations to which the 

company provided funding, including the National 

Urban League; the NAACP; the League of United Latin 

American Citizens; Howard University; Alpha Kappa 

Alpha Sorority; the Portland Life Center; the Harlem 

Dowling-West Side Center for Children and Family 

Services; New Jersey’s Special Supplemental Food Program for Women, Infants and Children; the National 

Council of Negro Women; the National Puerto Rican 

Coalition; and ASPIRA, Inc., of New Jersey (RJR 

Nabisco, Inc. 1986). 

At the community level, tobacco companies rely 

on athletic, cultural, and social events to promote their 

products’ images, often in association with small community agencies. In African American and Hispanic 

communities, tobacco companies frequently sponsor 

street fairs, jazz festivals, Little League baseball teams, 

soccer teams, symphony orchestras, auto races, and 

art exhibits, just as they do in white communities (Blum 

1986; Robinson et al. 1992b; Sanchez 1993). These contributions place community agencies in a particular 

dilemma, because many of the agencies’ programs 

depend directly or indirectly on contributions received 

from the tobacco industry. At the same time, acceptance of money and services from the tobacco industry may be perceived as an indirect endorsement of 

tobacco use. Community leaders generally are split 

in their opinions about the propriety of accepting support from tobacco companies and alcoholic beverage 

companies (Robinson et al. 1992a). Opponents argue 

that the costs of compromised integrity, implicit endorsement of tobacco and alcoholic beverages, and 

current and future increases in disease and death in 

these communities are far greater than the benefits 

these funds provide. Proponents argue that these 

funds—when made available for such purposes as 

scholarships, conferences, business development, 

health fairs, and the organizations’ survival—benefit 

the various racial/ethnic communities, particularly 

when other sources of financial support have been in 

short supply or unavailable. Strategies and policies 

that promote funding sources other than tobacco companies are needed to alleviate communities’ reliance 

on tobacco-related support (Satcher and Robinson 

1994). 

The tobacco industry also supports the operations and activities of racial/ethnic organizations by 

providing special services, such as the publication of 

resource guides and other materials (Blum 1986). For 

216 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

example, Philip Morris has biennially published the 

Guide to Black Organizations since 1981 (Philip Morris 

Companies Inc. 1992). The guide lists national, 

regional, and local African American nonprofit organizations throughout the United States, as well as African American state and regional caucuses of elected 

and appointed officials. Philip Morris also publishes 

and widely distributes two similar publications, the 

National Directory of Hispanic Organizations (Congressional Hispanic Caucus Institute, Inc. 1993) and the National Directory of Asian Pacific American Organizations 

1997–1998 (Organization of Chinese Americans 1997). 

Support for Education 

For years, the tobacco industry has contributed 

to programs that aim to enhance the primary and secondary education of children, has funded universities 

and colleges, and has supported scholarship programs 

targeting African Americans (the UNCF) and Hispanics (the National Hispanic Scholarship Fund). 

Philip Morris has contributed to Teach For 

America, a not-for-profit group that trains teachers, primarily those in racial/ethnic urban school systems, such 

as those in Baltimore City and the District of Columbia 

(Marriott 1992). In addition, both Philip Morris and R.J. 

Reynolds donate money to public school systems in 

racial/ethnic minority communities (Milloy 1990). 

For more than a century, the tobacco industry has 

provided financial support to historically and predominantly African American colleges and universities in the United States. This funding tradition can 

be traced to Richard Joshua Reynolds, who founded 

R.J. Reynolds about the time that African Americans 

were emerging from slavery. In 1891, Reynolds gave 

money to a school that eventually became WinstonSalem State University, a school that educated freed 

slaves (Russ 1993). 

The tobacco companies also have been strong 

supporters of the UNCF, which was founded in the 

mid-1940s to provide a central fund-raising arm for a 

number of small, struggling, predominantly African 

American private colleges and universities. When 

questioned in the mid-1980s about the appropriateness 

of accepting contributions from tobacco companies, a 

former head of the UNCF gave three reasons for accepting the contributions: (1) the companies had been 

longtime supporters of higher education for African 

Americans, even when the cause was not popular; 

(2) the contributions from the tobacco companies were 

too large to reject because the colleges needed the 

money to survive; and (3) the tobacco companies had 

factories in communities where the African American 

colleges and universities were located (Blum 1985). In 

addition to supporting the UNCF, tobacco companies 

have supported African American higher education 

in a variety of other ways, such as through other 

scholarships and internship programs (Robinson et al. 

1992b). 

In recent years, the tobacco industry has begun 

supporting adult literacy efforts. In 1990, Philip Morris joined with the Pew Charitable Trusts and the Philadelphia Mayor’s Commission on Literacy to launch 

the Gateway Program, an adult literacy campaign designed to serve as a national model. Philip Morris contributed $1.5 million to the program and an additional 

$1.5 million for media support (Robinson et al. 1992b). 

In yet another outreach effort, Philip Morris subsidized 

the Milwaukee County Youth Initiative, a program 

designed to help low-income and minority families 

become more involved in the education of their children (Haile 1991). 

Support for Political, Civic, and 

Community Campaigns 

The emergence of racial/ethnic minority political power, mostly at the local level, has provided yet 

another avenue for the tobacco industry to bolster its 

support of racial/ethnic communities. Although most 

of the contributions at the national level have gone 

to white legislators, two African American legislators 

were 14th and 16th on a list of tobacco industry-related 

campaign contributions received from January 1985 

through September 1995 (Fisher 1995). 

At the state and local levels the tobacco industry 

has been generous to all, including racial/ethnic 

legislators, particularly those in a position to vote on 

increases in tobacco excise taxes and smoking restrictions on the job and in public places. Since Californians passed Proposition 99, which raised the cigarette 

sales tax by 25 cents per pack, political contributions 

from tobacco companies in California rose from less 

than $800,000 in the 1985–1986 elections to more than 

$7.6 million in the 1991–1992 elections (Begay et al. 

1993). These politicians, some of whom are of racial/ 

ethnic origins, once elected, control how the excise tax 

revenues are spent and what proportion of the 

revenues is spent on tobacco control and tobaccoeducation projects. 

Other contributions have been made by the tobacco industry to civic leaders through such mechanisms as Brown & Williamson Tobacco Corporation’s 

Kool Achiever Awards, which are designed to recognize a dozen or so urban achievers “working to create 

long-term benefits for urban communities” (Brown & 

Factors That Influence Tobacco Use 217 
 

Surgeon General’s Report 

Williamson Tobacco Corporation 1993, back cover). 

Each recipient chooses a nonprofit organization 

to which Brown & Williamson donates $5,000. In 

1993, R.J. Reynolds began a similar campaign entitled 

Salem FreshsideTM Salute, which recognizes African 

Americans working to improve the conditions usually 

found in center cities by giving these individuals donations of $5,000. In addition, promotional campaigns 

directed at the nation as a whole can affect racial/ 

ethnic minority communities. For example, in 1989, 

Philip Morris sponsored a touring exhibition of the Bill 

of Rights. Philip Morris placed advertisements celebrating the freedoms guaranteed by the Bill of Rights 

in dozens of magazines and newspapers, including a 

large number of African American and Hispanic publications. Photographs of admired celebrity members 

of racial/ethnic groups appeared in the tobacco 

company’s advertisements. Such efforts engender 

good will and name recognition among various racial/ 

ethnic groups. Just as some organizations, such as 

COSSMHO and, more recently, the Tet Festival in San 

Jose, California, and the Dia De Fiesta Latina Day of 

the Del Mar Fair in California, have refused to accept 

tobacco industry dollars (Fernandez 1996; Levin and 

Perry 1996; San Diego Union-Tribune 1996), individuals are also refusing to accept similar tributes. For example, a community activist was awarded but declined 

to accept the Kool Achiever Award because of the ethical dilemma he perceived related to the high number 

of African Americans whose diseases or deaths are 

caused by tobacco use (Rosenberg 1993). 

Support for Cultural Activities 

Tobacco companies have been creative in their 

efforts to reach all members of society via cultural 

events (Johnson 1992b). Tobacco companies sponsor 

large museum exhibitions, concerts, and performances 

for the full spectrum of society. Advertisements for 

cigarettes and, in some cases, for smokeless tobacco 

are often placed conspicuously at these events, although sometimes the tobacco industry’s sponsorship 

is noted more subtly in catalogs and program notes. 

Some of the activities, however, are directed at racial/ 

ethnic communities and are designed to support or 

enhance racial/ethnic pride and culture—such as 

Mexican rodeos; American Indian powwows; racial/ 

ethnic minority dance companies; racial/ethnic parades and festivals; Tet festivals; Chinese New Year 

festivities; Cinco de Mayo festivities; and activities related to Black History Month, Asian/Pacific American Heritage Month, and Hispanic Heritage Month 

(Warner 1986; Maxwell and Jacobson 1989). 

In some instances, tobacco products are associated with popular community events through sponsorships and store promotions. In 1989, for example, 

Skoal Bandit smokeless tobacco was tied to the 

promotion of Miami’s Calle Ocho festival through live 

radio remotes from several 7-Eleven stores in the Miami area (Gross 1989). During that same year, the promotion of Skoal Bandit was associated with a Hispanic 

festival in Corpus Christi, Texas, and with the 10th 

anniversary car and truck show of Lowrider magazine 

(Gross 1989). Recently, the 1994 Little Saigon Tet Festival in Orange County, California, was sponsored by 

Marlboro and 555 State Express of London brands of 

cigarettes. Booths at the festival were used to promote 

the two brands of cigarettes through displays and the 

distribution of promotional items. 

The sponsorship of artistic events has been one 

of the fastest growing segments of special events 

marketing, and tobacco companies have taken full advantage of this trend to expand and strengthen their 

linkages with various racial/ethnic communities 

(Bergin 1990). The tobacco industry’s link with racial/ 

ethnic music and art is not new; for example, in the 

1950s, tobacco companies featured African American 

jazz artists in cigarette advertisements in Ebony magazine. However, these links are more complex today 

(Pollay et al. 1992; Robinson et al. 1992b). For example, 

in 1994, New York City art institutions that received 

funds from Philip Morris were placed in a difficult situation when the tobacco company asked them to inform city council members about the role that Philip 

Morris had played in sponsoring artistic events in New 

York City. At that time, the city council was considering a ban on cigarette smoking in most restaurants and 

public places, and Philip Morris was threatening to 

move the company headquarters away from New York 

City if such a ban was approved (Goldberger 1994). 

The headquarters did not move despite the city’s passage of a 1995 law that banned smoking in workplaces 

(except for physically separated, separately ventilated 

smoking rooms and private offices), restaurants seating more than 35 patrons, day care centers, and playgrounds (Smith 1995). 

Musical events have long been a primary outlet 

for targeting support among racial/ethnic groups. For 

example, jazz, rap, blues, rhythm and blues, salsa, 

gospel, and world music concerts are often heavily 

sponsored by tobacco companies and are identified 

with specific cigarette brands targeted toward African 

Americans, Hispanics, and Asian Americans and Pacific Islanders. Tobacco companies heavily promote 

these concerts on racial/ethnic minority radio stations, 

in the press, and through magazines that have large 

circulations (Robinson et al. 1992a,b). At these 

218 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

concerts, companies often promote their cigarette 

brands by naming events after the brands, by placing 

promotional signs on and around stages, and by distributing free cigarettes and other promotional items 

featuring cigarette brand logos. These musical events 

have included the Parliament World Beat Concert Series, Brown & Williamson’s Kool Jazz Festival, Benson 

& Hedges’s blues and jazz concerts, and Philip Morris’s 

Superband Series. The Superband Series was launched 

in 1985 by Philip Morris to support and publicize jazz 

as “America’s unique contribution to the field of music” (Jet 1990, p. 36). The Superband, which featured 

African American musicians, performed throughout 

the world and the United States. 

Racial/ethnic dance troupes and the visual arts 

have been strongly supported by tobacco companies. 

Philip Morris has contributed significantly to African 

American troupes, including the Alvin Ailey American Dance Theater and the Dance Theatre of Harlem 

(Blum 1989; Rothstein 1990; Jackson 1992; Johnson 

1992b). Philip Morris also has provided substantial 

funding to the Studio Museum in Harlem, one of the 

main repositories of African American paintings, 

sculptures, and crafts. In addition, tobacco companies 

have underwritten traveling art shows featuring African American and African artists and have displayed 

the artists’ work in corporate settings (Jackson 1992; 

Robinson et al. 1992b). Traveling exhibits of Hispanic 

and Asian American artists have received significant 

support from tobacco companies as well. 

One of the longest running cultural events in 

African American communities is the annual eightmonth tour of the Ebony Fashion Fair. Founded in 1958 

by the publisher of the leading African American 

magazine, this event is attended by more than 300,000 

women in 190 cities. From the late 1970s to the early 

1990s, R.J. Reynolds’s More cigarettes supported the 

fair (Assael 1990). Proceeds from the tour have benefited African American churches, sororities, and other 

charitable and civic organizations whose antidrug 

campaigns, health fairs, and other projects are cited in 

the program. When the show was supported by More 

cigarettes, fashion models lit cigarettes during walks 

down the runway. In addition to reciting the names 

of clothing designers, the announcer noted that the 

models smoked More cigarettes. Free samples of More 

cigarettes were distributed to members of the audience as they left the performance. At the Chicago performance of the 1984 Ebony Fashion Fair, R.J. Reynolds 

marked the UNCF’s 40th anniversary by donating a 

$250,000 ruby necklace to the fund as part of the tradition of giving rubies on 40th anniversaries (Joyner 1984; 

Blum 1985, 1986). 

Estimating how much money is actually spent 

by the tobacco industry on the sponsorship of racial/ 

ethnic cultural and social activities is difficult. Detailed 

financial records of tobacco manufacturers are not 

public record, and the financial information that is 

published in annual reports and similar company publications does not separate the amount of money spent 

on the promotion of cultural and artistic events among 

racial/ethnic groups from the amount spent on advertising and other forms of product promotion. 

Support for Sports Events 

Although the negative effect of tobacco on health 

has made direct links between tobacco companies and 

sports less tenable today than they were in the 1950s 

and 1960s, tobacco companies have increased their 

involvement in sports by sponsoring communitybased softball, golf, soccer, and baseball (Blum 1989; 

Robinson et al. 1992b). One such example is U.S. 

Tobacco’s Skoal Brand sponsorship of the Hispanic 

championship soccer tournament, Copa Nacional 

(Brandweek 1995). Tobacco companies have maintained 

a link to sports and racial/ethnic communities through 

such means as sponsoring the Jackie Robinson Foundation Awards Dinner. In 1995 alone, the six major 

cigarette-manufacturing companies in the United States 

spent $83 million to sponsor, advertise, or promote 

sporting events; to support individual athletes or group 

teams; to advertise in sports venues; and to promote 

items connected with sporting events (FTC 1997). Tobacco industry support for sports is consequential, in 

part, because of the perception among some youth, particularly African Americans, that athletic ability provides an avenue of personal advancement. 

Factors That Influence Tobacco Use 219 
 

Surgeon General’s Report 

Advertising and Promotion 

Advertising is an important influence on tobacco 

use initiation and maintenance, as documented in 

Preventing Tobacco Use Among Young People (USDHHS 

1994). Cigarette advertising and promotion may 

stimulate cigarette consumption by (1) encouraging 

children and adolescents to experiment with and initiate regular use of cigarettes, (2) deterring current 

smokers from quitting, (3) prompting former smokers 

to begin smoking again, and (4) increasing smokers’ 

daily cigarette consumption by serving as an external 

cue to smoke (CDC 1990a). In addition, cigarette advertising appears to influence the perceptions of 

youths and adults about the pervasiveness of cigarette 

smoking and the images they hold of smokers 

(USDHHS 1989, 1994). Cigarette advertising also may 

contribute to the perception that smoking is a socially 

acceptable, safe behavior and may produce new 

perceptions about the functions of cigarette smoking 

in social situations. All of these perceptions have been 

shown to be risk factors for the initiation of cigarette 

smoking (Lynch and Bonnie 1994; USDHHS 1994; 

Federal Register 1996). 

Unfortunately, the specific effect of advertising on 

youth in racial/ethnic minority communities is not well 

understood, to some extent because research is scarce 

on youth in racial/ethnic communities. Available data 

indicate that young people smoke the brands that are 

most heavily advertised. In 1993, the three most heavily 

advertised brands of cigarettes, Marlboro, Camel, and 

Newport, were the three most commonly purchased 

brands among adolescent smokers. More than 45 

percent of Hispanic and 63 percent of white teenagers 

reported purchasing Marlboro. African American 

teenagers most often chose Newport, one of the mentholated cigarettes heavily marketed to the African 

American community (Cummings et al. 1987; CDC 

1994a). Although combined sales of these three brands 

represented only 35 percent of the adult market share, 

they represented 86 percent of the adolescent market 

share. These data suggest that tobacco advertising influences brand preference among youths and that there 

are differences in preference among racial/ethnic 

groups (CDC 1994a). 

Another reason that research to date has been 

unable to quantify the specific effect of tobacco advertising on racial/ethnic groups is that advertising for 

tobacco products is ubiquitous and uses images, such 

as glamour, independence, and attractiveness, that 

appeal to all segments of society. Overall, tobacco 

products are among the most heavily advertised 

products in the United States. However, studies have 

documented that some tobacco products are advertised 

disproportionately to members of racial/ethnic 

groups, such as mentholated products to African 

Americans and brands named “Rio” and the earlier 

“Dorado” to Hispanics (Gloede 1985; Leviten 1985; 

Walters 1985). 

In a study of adolescents who had never tried 

smoking, Evans and colleagues (1995) reported an 

association between a measure they constructed on 

receptivity to tobacco marketing and a measure of susceptibility to begin smoking. Higher scores on the 

receptivity index were associated with increasing likelihood of being susceptible to start smoking. The 

association persisted, even after statistical control for 

exposure to other smokers, race/ethnicity, and other 

socioeconomic status variables. Racial/ethnic minority-group specific analyses were not conducted. The 

findings in this study, though suggestive, require 

further validation. 

Market segmentation is a well-developed strategy 

for crafting advertising campaigns that present particularly persuasive appeals to targeted audiences (Murphy 

1984). It has been suggested that the tobacco industry 

strategically targets new consumer groups (e.g., women, 

racial/ethnic groups, and youths) by developing advertisements that exploit the psychological interests and 

needs of those targeted populations (e.g., Basil et al. 

1991). A large and increasing portion of advertising and 

marketing is targeted to racial/ethnic groups, especially 

youth (Moore et al. 1996; Zbar 1996). The challenge for 

the audience is to distinguish the advertising that represents consumer goods with benefit or satisfaction from 

advertising that represents products that may harm the 

target community (Moore et al. 1996). Targeted tobacco 

advertising presents images of success, wealth, happiness, and sophistication, all of which are attractive to 

racial/ethnic groups, perhaps particularly in contrast 

with other, less flattering images of those communities 

presented by the news media. A recent article on the 

health of African American women discussed the attractive images used to target the African American 

community. “We have grown almost numb to negative 

images of ourselves in the media—Black teen girls surrounded by screaming babies or men in handcuffs. 

Except in cigarette or liquor advertisements. In these 

we are beautiful, confident, well-dressed, happy, 

wealthy, in love. . . ” (Villarosa 1994, p. 13). 

220 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Concern about targeted tobacco advertising has 

been the subject of various congressional hearings (e.g., 

U.S. Congress 1987, 1990). Efforts have been made by 

communities to counteract such advertising. Indeed, 

tobacco companies’ targeting of racial/ethnic communities appears in some cases to have created a reverse 

marketing effect, such as that seen with the African 

American community’s negative and forceful response 

to Uptown and X brand cigarettes (see Targeted 

Products later in this chapter). Recent data show that 

African Americans’ spending on tobacco decreased 

5 percent between 1994 and 1995 (Schmeltzer 1996), 

perhaps due in part to an adverse reaction to the targeted marketing of a harmful product (McIntosh 1995). 

Counteradvertising has also been used; one poster distributed by Harlem Hospital in 1991 depicted the 

Marlboro man lighting a cigarette for an African 

American child. The caption read, “They used to make 

us pick it. Now they want us to smoke it.” A television spot, “Rappers/Pick It,” produced by the 

California Department of Health Services, conveys a 

similar theme (Kizer et al. 1990, p. 76). 

Although many companies are sensitive about 

disclosing targeted marketing strategies, particularly 

efforts focused on racial/ethnic minority markets, recent analyses of marketing trends document tobacco 

companies’ efforts to sell their products to racial/ethnic groups and to youths (Davis 1987; Altman et al. 

1991; Johnson 1992a; Moore et al. 1996; Stoddard et al. 

1997). At least one major tobacco company, Philip 

Morris, has argued that it does not exclusively target 

any particular group (Nelson and Lukas 1990). Questions also have been raised about the appropriateness 

of using targeted advertising and promotional techniques when the quantity and intensity of these efforts 

are well beyond the proportional purchasing power 

of the targeted group or when particular promotional 

techniques such as billboard placements are used in 

quantities that are out of proportion to the population 

size of the targeted groups. Examples of targeted advertising and promotion that may be inappropriate include the overly frequent placement of billboards that 

advertise tobacco products in racial/ethnic enclaves, 

the use of cultural values and symbols valued by members of racial/ethnic groups to promote tobacco products, and the use of certain promotional practices (e.g., 

coupons, discounts, tie-ins, and free gifts). 

Magazine Advertisements 

Certain tobacco products are advertised disproportionately to members of racial/ethnic groups. For 

example, menthol cigarettes are more frequently 

advertised in magazines targeting African Americans 

than in magazines directed at the general public 

(Cummings et al. 1987). An analysis of one year of 

issues (June 1984 through May 1985) of three magazines primarily directed at African Americans—Jet, 

Ebony, and Essence—and of four magazines directed 

at the general population—Newsweek, Time, People, 

and Mademoiselle—found that 12 percent more advertisements for cigarettes appeared in the African American magazines. In addition, 65.9 percent of the 

cigarette advertisements in the African American 

magazines were for menthol cigarettes, compared with 

15.4 percent of those in the general population magazines (Cummings et al. 1987). Indeed, Newport, a 

menthol brand, is the number one preferred cigarette 

among African American adults and youth (CDC 

1990b, 1994a). 

Outdoor Advertisements 

Early research showed that marketing approaches such as billboards and point-of-sale displays 

have been particularly effective in reaching African 

Americans. In one early study, Bullock (1961) sampled 

1,106 African Americans and 537 whites from Atlanta, 

Birmingham, Houston, Memphis, and New Orleans 

to assess a variety of consumer behaviors. Bullock 

found that billboards and point-of-sale materials were 

particularly effective in reaching a high proportion 

of African American consumers and that African 

American consumers were more likely than whites to 

trust advertising. In addition, a disproportionately 

high number of billboards and other outdoor advertisements promoting cigarettes and other tobacco products have been placed in racial/ethnic minority 

communities. A recent study in Los Angeles found 

that the density of cigarette advertisements on billboards was 4.6 times greater in the city proper than in 

the suburbs (Ewert and Alleyne 1992). In a study conducted in San Diego, Elder and colleagues (1993) found 

that the highest proportion of billboards featuring tobacco products was in Asian American (13.0 percent) 

neighborhoods, followed by African American (9.6 percent), Hispanic (4.7 percent), and white (1.1 percent) 

neighborhoods. The volume of outdoor advertising 

in Asian American neighborhoods was relatively low, 

although the proportion of that space devoted to tobacco products was high (Elder et al. 1993). In an earlier study, Mitchell and Greenberg (1991) found that 

most billboards in racial/ethnic communities in four 

New Jersey cities were predominantly dedicated to 

advertised alcoholic beverages and tobacco products. 

In several urban centers, the proportion of billboard 

Factors That Influence Tobacco Use 221 
 

Surgeon General’s Report 

tobacco advertising has been found to be higher in African American neighborhoods than in white areas 

(Tuckson 1989; Mitchell and Greenberg 1991; Mayberry 

and Price 1993). Stoddard and colleagues (1997) documented tobacco billboard advertising in four neighborhoods (African American, Asian American and 

Pacific Islander, Hispanic, and white) in Los Angeles 

during 1993 and 1994. Tobacco billboard density (the 

number of billboards per mile) was highest in African 

American communities, intermediate in Hispanic and 

Asian communities, and lowest in white communities. 

The models in billboards in African American neighborhoods were more likely to appear younger than in 

the other neighborhoods. In addition, 91 percent of 

the billboards in African American neighborhoods featured an African American as the central character; in 

the other three neighborhoods, whites portrayed the 

central characters. 

In-Store Promotions 

In-store and over-the-counter promotions for tobacco products also seem to disproportionately target 

racial/ethnic communities. For example, in racial/ 

ethnic neighborhoods in San Diego, Asian American 

retail outlets had the highest average number of tobacco promotion displays (6.4), compared with Hispanic (4.6) and African American (3.7) stores (Elder et 

al. 1993). In addition, low-cost or generic cigarettes 

that have begun to capture increasing market shares 

may be particularly effective as part of a targeted campaign directed at members of racial/ethnic groups 

with low-socioeconomic status and for whom price 

may be an important consideration in the purchase of 

cigarettes (Assael 1990). 

Convenience store owners often are eager to 

promote tobacco products, which account for about 

26.5 percent of their total sales (National Association 

of Convenience Stores 1993). In such stores, tobacco 

companies frequently promote their products through 

special displays and point-of-sale promotions that provide monetary or product allowances for the store 

owners (Cummings et al. 1991; Wildey et al. 1992; 

Davis 1993; USDHHS 1994). In a study of 23 supermarkets and convenience stores in San Diego, Wildey 

and colleagues (1992) found that 52 percent of store 

owners reported receiving payments from tobacco 

companies for displaying advertisements in their 

stores and that 69 percent of the stores displayed tobacco advertisements on the outside walls, windows, 

or parking lot signs. The researchers also found that 

stores in Asian American neighborhoods were more 

likely than stores in white communities to have 

outside advertisements for tobacco products. A San 

Francisco study found that a large number of small 

stores in racial/ethnic minority neighborhoods display 

outside placards and small billboards for tobacco products (Gerardo Marín and colleagues, unpublished 

data). About 57.6 percent of small stores in predominantly African American neighborhoods displayed at 

least one advertisement for tobacco products, compared with 37.7 percent in predominantly Hispanic 

neighborhoods and 28.6 percent in predominantly 

Asian American and Pacific Islander neighborhoods. 

Racial/Ethnic Symbols, Names, and Events 

Another area of concern about targeted advertising and promotion is the use of clearly identifiable 

racial/ethnic models; group-specific messages, such 

as salutes to Latino community organizations during 

Hispanic Heritage Month, and group-relevant placements. Examples of group-relevant placements are 

cigarette advertisements appearing during Black History Month and featuring pictures or quotations of 

African American leaders and Philip Morris’s salute 

to its Bill of Rights campaign during news coverage of 

Nelson Mandela’s release from prison. These advertisements target racial/ethnic communities by making use of symbols and events that are held in high 

esteem by community members. 

Individuals’ psychosocial characteristics are commonly used in the design of targeted advertising and 

marketing campaigns (Basil et al. 1991). Consumers, 

particularly those who identify with an racial/ethnic 

group’s culture, tend to prefer buying goods that are 

specifically advertised to their cultural group. 

Deshpande and colleagues (1986) found that Hispanics who strongly identified with their racial/ethnic 

culture preferred Spanish language advertising, were 

more likely than those with less cultural identification 

to maintain brand loyalty, and were more likely than 

those with less cultural identification to buy prestige 

brand goods and those advertised specifically to their 

racial/ethnic minority group. In addition, Lee and 

Barnes (1989–1990) found that advertisements targeting African Americans differ from those directed at the 

general population in that they feature certain bright 

colors. 

Tobacco product promotions also feature symbols and names that have special meaning for racial/ 

ethnic groups. Certain names have special significance 

for particular groups (Uptown among African Americans), the use of non-English names may appeal to 

certain linguistic groups (Rio and Dorado among 

Hispanics), and the use of certain words can conjure 

222 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

symbols that are meaningful to a particular group 

(American Spirit among American Indians). The use 

of racial/ethnic events and symbols to market tobacco 

can present a complex issue that is difficult for 

communities to resolve. For instance, the American 

Spirit cigarette package portrays an American Indian 

smoking a pipe, and the product’s literature features 

American Indian cultural themes, stating that the 

American Indian custom was to smoke tobacco leaves 

the “natural way” and that American Spirit cigarettes 

are “natural” cigarettes. In early 1997, the American 

Indian Tobacco Education Network criticized the Sante 

Fe Tobacco Company for exploiting sacred Indian traditions and imagery to sell its tobacco products. The 

Sante Fe Tobacco Company countered that it honors 

Indian traditions in its use of community symbols and 

even donates tobacco to tribes for ceremonial purposes 

(Guthrie 1997). The fact remains that American Spirit 

cigarettes contain tobacco with amounts of tar and 

nicotine similar to those of commercial brands and are 

thus dangerous to health, despite their lack of additives. Although targeted marketing of products may 

bring economic benefits to racial/ethnic communities, 

when such marketing is for a harmful product such as 

cigarettes, the target community is challenged to 

choose between potential economic gain and social 

recognition versus the inevitable long-term adverse 

health outcomes from use of the product (Moore et al. 

1996). 

Cigarette advertisements also have been accused 

of trivializing social causes and cultural values. For example, a Virginia Slims advertisement that appeared in 

the July 1994 issue of Life uses the concept of racial/ethnic equality to promote use of the product. In addition, 

certain tobacco product advertisements have used visual 

images, such as American Indians as warriors, that demean the culture and insult some individuals (Green 

1993). 

Another significant concern is the effect that 

targeted tobacco advertising may have on recent immigrants. For many immigrants, the advertising of 

cigarettes in their country of origin has helped mold 

their attitudes and perceptions of tobacco use. These 

perceptions in turn create expectations about the 

social effects of cigarette smoking as portrayed in advertisements, as well as brand recognition and brand 

loyalties toward the most frequently advertised 

brands. Targeted promotional and marketing practices 

also can affect the decisions of consumers who have 

recently migrated to the United States and who, in 

general, have not been exposed to marketing techniques and promotional approaches common in the 

United States. Immigrants not exposed to lifelong 

learning from the commercial practices of a market 

economy may be less critical and overly trusting of 

the messages and implied promises presented in advertisements. Webster (1990–1991) found that highly 

acculturated Hispanics rated certain consumer products as defective and overpriced and claimed that advertising was problematic, whereas less acculturated 

Hispanics were more accepting of such defective products and saw advertising not only as informative but 

also as enjoyable. Immigrants also respond differently 

to promotional techniques with which they are unfamiliar. For example, Hispanics who have a low level 

of acculturation may not respond to certain novel promotional techniques such as the use of coupons 

(Donthu and Cherian 1992) but are more influenced 

by radio and billboard advertisements and point-ofsale displays (Webster 1992). Other studies have also 

found that promotional techniques have differential 

effects on various sectors of the Hispanic population. 

The more acculturated Hispanics report being primarily influenced by magazine advertisements, brochures, product labels, and consumer guides, such as 

Consumer Reports and the Yellow Pages (Webster 1992). 

Targeted Products 

Although a few cigarette brands have names that 

imply specific racial/ethnic minority targeting (e.g., Rio 

and Dorado for Hispanics), their promotion has been 

limited to a few states. The recent introduction of 

American Spirit seems to be directed at American 

Indians as well as youths and individuals preferring 

natural products. In addition, Japan Tobacco Inc. has 

begun to market its top-selling brand, Mild Seven, in 

the United States (Stebbins 1990; Sesser 1993). The 

brand is being promoted as a cigarette manufactured 

by Asians for Asians, and full-page advertisements appear in magazines primarily targeting Asian Americans 

(Koeppel 1990b). Mild Seven billboards also have appeared in Koreatown and Little Tokyo in Los Angeles 

as well as in other U.S. cities with large Asian American populations. 

One of the best examples of product targeting 

was the cigarette Uptown, designed by R.J. Reynolds 

in the 1980s to reach African American smokers 

(Dagnoli 1989; Simmons 1989; Koeppel 1990a; 

Robinson and Sutton, in press). The attempted 

introduction of this cigarette is a case study in racial/ 

ethnic product targeting. The characteristics, packaging, and planned promotion of Uptown cigarettes 

allegedly were designed specifically for African Americans. The menthol formulation of this new brand was 

designed to compete directly with Lorillard’s Newport 

Factors That Influence Tobacco Use 223 
 

Surgeon General’s Report 

cigarette, which was one of only three full-price cigarettes to gain market shares in 1989 along with Philip 

Morris’s Marlboro and Virginia Slims cigarettes 

(Dagnoli 1989). In 1986, Newport was the leading 

brand of cigarettes among African American smokers, 

ahead of Brown & Williamson’s Kool cigarettes and 

R.J. Reynolds’s Salem cigarettes (Simmons 1989; CDC 

1990b). The mentholated Uptown cigarettes were to 

be packed with their filters down in the belief that 

African American blue-collar workers often open their 

cigarettes from the bottom to avoid crushing the filters or having to put unwashed hands on the part of 

the cigarette that goes into their mouth (Ramirez 1990). 

Furthermore, in its statement announcing Uptown 

cigarettes, the company defined African Americans as 

the primary market for the new brand. Unlike Newport cigarettes, which were purported to be aimed at 

all smokers rather than just African Americans, R.J. 

Reynolds was specific (Dagnoli 1989). “We expect 

Uptown to appeal most strongly to black smokers,” 

said Lynn Beasley, vice president of strategic marketing for the company. “Our research led us to believe 

that Uptown’s blend . . . will be an appealing alternative to smokers currently choosing a competitive 

brand. We have developed a product based on research that shows that a significant percentage of black 

smokers are currently choosing a brand that offers a 

lighter menthol flavor than our major menthol brand, 

Salem” (Philadelphia News Observer 1990, p. 7). 

Uptown cigarettes were to yield 19 milligrams 

of tar per cigarette, which was the highest level of tar 

in all of R.J. Reynolds’s cigarette brands, with the exception of unfiltered Camel cigarettes. The planned 

advertisements were to depict African American 

couples enjoying cigarettes in a sophisticated urban 

environment with the slogan “Uptown. The Place. 

The Taste” (Koeppel 1990a). The marketing plan for 

Uptown cigarettes was designed to take advantage of 

media that were particularly effective in reaching 

African Americans, including billboards, transit advertising, bus shelters, point-of-purchase signs, 

and advertisements in racial/ethnic newspapers and 

magazines. 

The introduction of Uptown cigarettes was 

planned for the first week in February 1990 to coincide with Black History Month activities, including 

receptions, exhibits, festivals, award ceremonies, and 

other events highlighting the African American experience. Promoting Uptown cigarettes during this high 

level of activity—through the distribution of free 

samples and the underwriting of events—would 

afford R.J. Reynolds a prime opportunity to promote 

the new brand (Simmons 1989). 

R.J. Reynolds selected Philadelphia as the test 

market site because of its demographics. In 1990, the 

city’s population was approximately 40 percent African American and was served by several African 

American newspapers. In addition, African Americans tended to live in distinct neighborhoods that could 

be reached effectively through billboards and transit 

advertising. Furthermore, unlike some communities 

that had mobilized against excessive billboard advertising of alcoholic beverages and tobacco products, 

Philadelphia’s African American community had been 

quiet in this respect. 

In the wake of a firestorm of negative national 

publicity (see Chapter 5), R.J. Reynolds withdrew its 

plans to test-market Uptown cigarettes in Philadelphia. 

The protest against this targeted product involved 

community members, civic and religious leaders, 

health professionals, and then-Secretary of Health and 

Human Services Dr. Louis W. Sullivan. Ultimately, R.J. 

Reynolds decided to withdraw Uptown cigarettes from 

the market permanently. 

The same leadership and strategy were used again 

in Boston in early 1995 and similarly resulted in the 

withdrawal of a new brand of cigarettes called “X,” 

thought to be targeted to African Americans because of 

its red, green, and black packaging and the suggestion 

of the name of noted leader Malcolm X. In this instance, 

however, both the manufacturer and the distributor 

denied that the brand was targeted to African Americans or any other racial/ethnic market (Jackson 1995) 

(see Efforts to Control Tobacco Advertising and Promotion in Chapter 5). 

In January 1997, R.J. Reynolds released a mentholated version of Camel cigarettes. R.J. Reynolds had 

last marketed a mentholated brand of Camels in 1966 

(Tobacco Merchants Association of the United States 

1978). Approximately three-fourths of African American smokers smoke mentholated cigarettes (USDHHS 

1990) and Camel cigarettes are popular, so the African 

American community has been concerned that a new 

menthol brand may escalate smoking among African 

Americans. In an event similar to that precipitating 

the withdrawal of Uptown cigarettes, key religious 

leaders, led by the National Association of African 

Americans for Positive Imagery, launched a national 

crusade against the new brand extension of Camel 

Menthols (Rotzoll 1997). 

224 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Psychosocial Determinants 

Psychosocial variables help explain why people 

start using tobacco (initiation), why some continue 

using it (maintenance), and why some stop using 

tobacco products (cessation). This section of the chapter provides a summary of research to date on the 

factors associated with initiation, maintenance, and 

cessation of tobacco use among ethnic groups. Unfortunately, the literature is sparse on individual and interpersonal factors that influence tobacco use among 

African Americans, American Indians, Alaska Natives, 

Asian Americans, Pacific Islanders, and Hispanics. 

Research and etiologic theory on smoking and 

smokeless tobacco use have largely excluded members 

of racial/ethnic groups. In fact, few researchers have 

included persons other than whites as part of their studies. Although research findings based on samples of 

the majority white population may be applicable to 

racial/ethnic minority populations, such generalizability has not been sufficiently studied. Racial/ 

ethnic groups may have different exposure levels and 

different reactions to risk factors or protective conditions than do whites. Furthermore, cultural differences 

in values, norms, expectancies, and attitudes may differ among members of various racial/ethnic groups. 

These differences, in turn, may influence the prevalence 

of cigarette smoking in a particular racial/ethnic group 

and the relationship between smoking behavior and associated risk factors (Marín et al. 1990a; Vander Martin 

et al. 1990). Certain experiences and values associated 

with tobacco use thus may be unique to some racial/ 

ethnic groups and may not be relevant to others. 

Understanding group-specific and community-based 

factors is necessary to help shape the development of 

culturally appropriate interventions. (Interventions are 

detailed in Chapter 5. For a detailed discussion of the 

range of variables that prompt youths to start smoking 

and to use smokeless tobacco, see Preventing Tobacco Use 

Among Young People, USDHHS 1994.) 

Initiation and Early Use of Tobacco 

Much of the research on tobacco use among 

racial/ethnic minority groups has focused primarily 

on a constellation of risk factors that affect people’s 

behaviors (Bry et al. 1982; Newcomb et al. 1986, 1987; 

Moncher et al. 1990; Scheier and Newcomb 1991; FelixOrtiz and Newcomb 1992; Newcomb and Felix-Ortiz 

1992; Vega et al. 1993). These studies have assessed 

environmental, behavioral, psychological, and societal 

attributes proposed by the various theories of tobacco 

use initiation (Ajzen and Fishbein 1970; Jessor and 

Jessor 1977; Kandel 1980; Yamaguchi and Kandel 1985; 

Elder and Stern 1986; Newcomb and Bentler 1988; 

Chassin et al. 1990, 1992), considering these attributes 

as individual risk factors or as a set of variables that 

affect an individual’s behavior (Hawkins et al. 1992). 

Some studies have proposed that the particular factors that increase an individual’s vulnerability are not 

as important as the accumulation of such factors in a 

person’s life and that tobacco use is but one of many 

responses people use to cope. Investigators have focused on some environmental and behavioral factors 

(such as parental and peer smoking or the availability 

of cigarettes) that may be useful in developing prevention strategies, but they have paid less attention to other 

equally important environmental conditions (such as 

price, access, exposure to advertising, economic history, 

customs and practices associated with tobacco in the 

native country, and tobacco industry influence on 

community organizations and leaders) that are differentially related to tobacco use and initiation. 

Some investigators have studied the onset of 

adolescent smoking as a phenomenon of gradual passage through various cognitive and behavioral stages 

of change—for example, from abstaining to using tobacco regularly (Conrad et al. 1992). Following 

Prochaska and DiClemente’s (1983) paradigm for 

studying smoking cessation, Stern and colleagues 

(1987) found that a predominantly white sixth-grade 

population progressed through stages, such as 

precontemplation (when the youth would not even 

consider smoking), to decision making (thinking about 

taking up the behavior and experimenting with 

cigarettes), to maintenance (regular smoking). Similar 

results were found in a study of California high school 

students, about one-third of whom were Hispanic 

(Elder et al. 1990), but potential differences between 

white and Hispanic students were not fully explained. 

More recently, Pierce and colleagues (1996) found 

that baseline susceptibility to smoking (defined as the 

absence of a firm decision not to smoke) was a stronger independent predictor of experimentation than the 

presence of smokers among either family or best 

friends. In this study, African American, Asian American, and Pacific Islander adolescents were significantly 

less likely to experiment than whites or Hispanics. 

However, exposure to smokers was more important 

than susceptibility to smoking in distinguishing 

Factors That Influence Tobacco Use 225 
 

Surgeon General’s Report 

adolescents who progressed to established smoking 

from those who remained experimenters. African 

American, Asian American, and Hispanic adolescents 

appeared less likely than whites to become established 

smokers (Pierce et al. 1996). 

African Americans 

A few studies have tried to identify variables that 

predict cigarette smoking among African Americans. 

Brunswick and Messeri (1983) examined five domains 

of variables to assess their effects on the onset and continuation of cigarette smoking among 379 African 

Americans aged 18–23 years who resided in the 

Harlem area of New York City. In this eight-year 

prospective study, multiple regression analyses 

showed that variables in each of five domains— 

personal background, school achievement, family and 

peer orientations, emotional conflict, and health attitudes and behaviors—were significant predictors of 

smoking initiation, although the patterns of influence 

differed by gender. In further analyses, Brunswick and 

Messeri (1984) found that poor school achievement 

predicted the onset of cigarette smoking among 

the young men and women. In addition, young 

women who reported higher cigarette use had low selfefficacy and were worried more about school. 

Among white youths, the presence of a best 

friend who smokes is a significant predictor of smoking, but the data on African American youths are 

contradictory. Some studies have shown that having 

peers who smoke is a poor predictor of cigarette smoking among African American youths (Headen et al. 

1991), whereas others have found the opposite (Botvin 

et al. 1992, 1993). Botvin and colleagues (1993) found 

that the most powerful predictor of cigarette smoking 

among those students initially sampled was having 

friends who smoke, together with personal factors such 

as lack of assertiveness in refusing cigarettes. A study 

of 757 African American and Hispanic seventh graders in six New York City public schools yielded similar results (Botvin et al. 1994). 

A few studies have analyzed retrospectively the 

predictive power of various sets of variables. Benson 

and Donahue (1989), for example, studied cigarette 

use among African Americans and whites by analyzing data from the 1976, 1979, 1982, and 1985 National High School Senior Surveys that were part of the 

University of Michigan’s Monitoring the Future (MTF) 

Project. The researchers analyzed 10 predictors of cigarette use: personal importance of religion, region of 

the country where respondents resided, gender, school 

type, community size, college plans, hours worked, a 

father present, level of parental education, and maternal employment. For each year examined, the 

researchers found that the association between these 

10 variables and cigarette use was substantially lower 

for African American high school seniors than for 

white high school seniors. Among both African Americans and whites, cigarette smoking was associated with 

the frequency with which the respondents went out at 

night, low levels of religiousness, and lack of concrete 

plans for college. In another study, Wallace and 

Bachman (1991) analyzed data from the MTF surveys 

for the years 1985–1989. They found that among African American high school seniors, four variables were 

significantly associated with cigarette smoking in the 

30 days preceding the survey: living in a nonurban 

area, being truant, frequently attending rock concerts, 

and having peers who used cigarettes. Among white 

high school seniors, 10 variables were significantly 

associated with cigarette use: being female, living in 

a single-parent family, having low attachment to 

school, being truant, going to parties, going to rock 

concerts, doing poorly in school, not being committed 

to future education, spending evenings out for fun and 

recreation, and having peers who used cigarettes (these 

last 4 variables were also associated with cigarette use 

among African Americans, but the association was 

stronger among whites). 

Weinrich and colleagues (1996) examined 

the relationship among three factors—adolescent 

smoking under stress, psychological distress, and 

social support—among 1,168 sophomore and junior 

high school students. They found that race was 

strongly associated with smoking to cope with stress, 

as measured by indices of anger/anger control, depression, somatization (expression of anxiety in physical 

symptoms), anxiety, obsessive/compulsive behavior, 

and social support. In each case, white students were 

more likely than African American students to engage 

in stress-related smoking. 

Also using a risk factor approach, Farrell and 

colleagues (1992) found that among 1,352 African 

American adolescents from the Southeastern United 

States, the following risk factors were associated with 

cigarette use: being home alone after school, having 

friends who approved of and used drugs, knowing 

adults who used drugs, feeling pressured to use drugs, 

expecting to use drugs in the future, being highly involved in delinquent behavior, having a history of 

trouble with the police, and having used cigarettes and 

alcohol previously. As noted, comparison of these 

studies is hampered by the noncomparability of the 

variables assessed. 

226 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

American Indians and Alaska Natives 

Among American Indians and Alaska Natives, 

tobacco use has a long and unique history that includes 

its use in rituals and spiritual ceremonies (WeibelOrlando 1985; Siegel 1989). Despite this important history, little is known about current predictors of the 

initiation of cigarette smoking and smokeless tobacco 

use among young American Indians and Alaska 

Natives. Schinke and colleagues (1989) have reviewed 

the scant literature and theories regarding tobacco use 

and believe that because of the historical association 

of tobacco with spiritual rites (Weibel-Orlando 1985), 

its contemporary daily use is also imbued with positive cultural attributes. But more behavioral explanations for tobacco use among American Indian and 

Alaska Native youths include peer pressure and 

expected pharmacologic effects (Schinke et al. 1990). 

In a study of cigarette smoking initiation among 

North American Indians, Pickering and colleagues 

(1989) surveyed a sample of 689 Cree schoolchildren 

aged 9–18 years in Canada’s James Bay Region. Factors associated with being a smoker included being 

older, being female, having a mother who smoked, and 

having a best friend who smoked. In a larger study, 

conducted in the northwestern United States, Moncher 

and colleagues (1990) examined tobacco use in a crosssectional sample of 1,147 fourth and fifth graders of 

American Indian and Alaska Native descent. The researchers assessed 16 possible risk factors related to 

peer and family use of various drugs, school adjustment, intentions to use various drugs, quality of family relationships, nondrug-related deviant behavior, 

cultural identity, and religiousness. All of the 16 risk 

factors correlated with the prevalence of any current 

or ever use of cigarettes or smokeless tobacco by these 

children. 

In an earlier study, also in the northwestern 

United States, Hall and Dexter (1988) studied smokeless tobacco use in a sample of 1,180 adolescents that 

included 257 American Indians. Multiple regression 

analyses revealed that among male adolescents, 

smokeless tobacco use was significantly associated 

with having friends who used smokeless tobacco; with 

cigarette smoking; and with tobacco use by the youths’ 

siblings, father, and other relatives. Among female 

adolescents, a similar pattern was observed, except 

that age also was positively associated with more 

smokeless tobacco use. Other explanations of tobacco 

use may include the relatively weak tobacco control 

infrastructure within American Indian communities 

and the presence of other environmental factors, such 

as advertising, that promote the use of tobacco products (Hodge 1995; Robinson et al. 1995). 

Asian Americans and Pacific Islanders 

Research on the factors that influence initiation 

of tobacco use among Asian Americans is sparse, and 

there is no such information about Pacific Islanders. 

Zane and Sasao (1992) reviewed the literature to identify possible explanations for the use of substances (including tobacco) among Asian Americans and Pacific 

Islanders. They mention several influences observed 

in other populations that may be relevant for Asian 

Americans and Pacific Islanders: (1) multiple 

stressful life events related to cultural adjustment; 

(2) culture-specific social skills needed in the United 

States, particularly direct self-expression, assertiveness, and individualism, which are often the opposite of traditional Asian and Pacific Island values 

and role expectations; and (3) family cohesion, which 

may reduce the role of peer influences that are central 

among members of other racial/ethnic groups. 

Wiecha (1996) studied 226 Vietnamese adolescents in two public middle schools and two public high 

schools in Worcester, Massachusetts, to examine the 

correlates and patterns of tobacco use. Four factors 

were independently and significantly associated 

with smoking among Vietnamese adolescents: male 

gender, older age, smoking by friends, and reporting 

carrying a weapon in the last month. Other factors 

that suggested associations but did not reach statistical significance included performing poorly in school, 

ever using marijuana, and fighting. Acculturation was 

inversely associated with current cigarette smoking, 

i.e., study participants who were more acculturated, 

as indicated by longer time in the United States, better 

spoken English, or no use of Vietnamese translation 

on the survey, were less likely to be current smokers. 

Findings also suggest that the adolescents in this study 

knew less about the health consequences of cigarette 

smoking and might share a lower-than-average 

perceived susceptibility to cancer (Wiecha 1996). 

Data from adults may be of use in identifying 

factors related to initiation among youths. Chen (1993), 

for example, found that the influence of friends or 

peers was the most frequent reason for smoking initiation reported by 13 adult Cambodian immigrant 

men. Data collected in 1991 indicate that among 296 

adult Chinese Americans in Oakland, California, 

40 percent of those who smoked reported that they 

began smoking “to be sociable” (Rod Lew and Art 

Chen, unpublished data). Other factors mentioned 

frequently were peer pressure (25 percent) and 

boredom (16 percent). 

Factors That Influence Tobacco Use 227 
 

Surgeon General’s Report 

Hispanics 

Research on why Hispanics begin to smoke often is narrowly focused on subgroups, such as those 

from a specific city or with a particular national background. Smith and colleagues (1991), using a crosssectional design, examined numerous potential factors 

affecting cigarette smoking and intentions to smoke 

among Puerto Rican teenagers in Boston, Massachusetts, and Hartford, Connecticut. Few statistically significant associations were found. Among Puerto Rican 

male adolescents, current cigarette smoking was associated with greater acculturation, more close friends 

who smoked, older age, and greater exposure to smoking at recreational activities. Among female Puerto 

Rican teenagers, the only factor associated with smoking was having close friends who smoked. In this 

study, the smoking status of parents had no effect on 

teenagers’ smoking behavior. 

Three studies have analyzed possible factors 

associated with tobacco use among Hispanic youths 

in the New York City area. Among Puerto Rican and 

Dominican seventh graders (Bettes et al. 1990), the 

researchers found that tobacco use was unrelated 

to language use (a possible proxy variable for acculturation) but was significantly associated with negative self-esteem, lower psychological well-being, 

higher psychological distress, and risk-taking. In a 

subsequent study, Dusenbury and colleagues (1992) 

examined possible factors associated with smoking 

experimentation and current cigarette use among 

New York City Hispanic youths aged 10–18 years. The 

researchers found an almost identical set of significant 

factors for both experimental and current use of cigarettes. These predictors included being older; having 

poor academic performance; having friends, parents, 

and siblings who smoked; believing that smoking was 

highly normative; and having parents with neutral or 

favorable attitudes toward cigarette smoking. More 

recently, Dusenbury and colleagues (1994) found that 

among Hispanic sixth- and seventh-grade students in 

New York City, those who smoked cigarettes tended 

to be older and to have a greater proportion of friends 

and relatives who smoked. They also found that 

speaking both English and Spanish at home and with 

friends (a behavior related to biculturalism) increased 

these students’ probability of smoking cigarettes. 

Separate analyses for boys and for girls showed that 

boys from bilingual homes were more likely to smoke; 

however, this was not true among girls. Data from 

two Southwestern cities indicate that a low level of 

maternal education and low grades obtained in school 

were associated with cigarette smoking among Hispanic youths (Schinke et al. 1992). 

Cowdery and colleagues (1997) analyzed cohort 

data collected in the 1989 and 1993 Teenage Attitudes 

and Practices Survey (TAPS) from a nationally representative sample of Hispanic adolescents aged 15–22 

years in 1993. They found that among Hispanic adolescents, the most strongly associated risk factor for 

smoking initiation was peer smoking. Additionally, 

not reporting a dislike for being around smokers 

and believing that smoking helps people relax and reduces stress were associated with an increased risk of 

smoking among males and females. The belief that 

smoking helps keep weight down was significantly 

associated with smoking among females. Among 

males, believing that there was no harm in an occasional cigarette, that smoking reduces boredom, and 

that smoking helps ease nervousness at social events 

were all associated with an increased risk of smoking. 

School participation may be an important predictor of tobacco use among Hispanics because they 

have the highest high school dropout rates of the major racial/ethnic groups in the United States (Kaufman 

and Frase 1990; Tomás Rivera Center 1993). Among 

white youths, dropping out of high school is a distinct 

correlate of cigarette use (Weng et al. 1988), but the 

results are not as clear for Hispanics. Chavez and colleagues (1989) studied three groups of Mexican American respondents—a group of youths who had dropped 

out of school, a group of youths at serious academic 

risk of dropping out of school, and a control group— 

from three Southwestern U.S. locations that varied in 

population size. Among Mexican American male 

youths, those at risk of dropping out of school and 

those who had dropped out of school had a higher 

prevalence of cigarette use but a lower prevalence of 

smokeless tobacco use than the control group. No significant differences in tobacco use were found among 

the three groups of Mexican American female youths. 

Watts and Wright (1990) compared Mexican American adolescents in Texas who were incarcerated with 

those who were attending high school and found that 

both minor delinquency and violent delinquency were 

significantly associated with tobacco use. 

The results from a recent study by Felix-Ortiz and 

Newcomb (1992) provide additional insights into the 

variables related to smoking among Hispanic adolescents. The researchers assessed risk factors and 

protective factors as predictors of both the frequency 

of cigarette smoking and the quantity of cigarettes 

smoked. Multiple regression analyses showed that 

among Hispanic boys (but not among girls), risk 

factors such as low academic achievement, low law 

abidance, low religiousness, and high level of depression significantly predicted both the quantity of 

228 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

cigarettes smoked and the frequency of smoking. In a 

more recent study, Felix-Ortiz and Newcomb (1995) 

found that neither familiarity with Hispanic culture 

nor familiarity with the larger U.S. culture was directly 

associated with tobacco use among boys and girls. 

Among Hispanic boys, cigarette use was associated 

with less respeto—a cultural value that grants prerogatives to adults and others with social power and that 

refers to a sense of personal self-worth. Among 

Hispanic girls, cigarette use was related to more involvement in Hispanic groups and political activities. 

A significant interaction was found between Englishand Spanish-language proficiency (usually considered 

a proxy measure of acculturation) and frequency of 

cigarette smoking among both boys and girls. For 

example, Hispanic youths with poor English- and 

Spanish-language skills had the highest frequency of 

cigarette use, whereas those with poor Englishlanguage skills but strong Spanish-language skills reported the lowest frequency of cigarette use. Hispanic 

youths with strong English-language skills had moderate levels of cigarette smoking frequency, regardless 

of their degree of Spanish-language proficiency. 

Another study of 1,411 females of Latino origin 

(Latinas) found differences in knowledge and perceptions about cigarette smoking between Spanishlanguage and English-language/bilingual young 

women (Campbell and Kaplan 1997). In this study, 

Latinas who either spoke English or were bilingual 

were less likely than their counterparts who spoke only 

Spanish to acknowledge the danger associated with 

smoking an occasional cigarette or to recognize the 

difficulty in quitting smoking, were more likely to 

identify beneficial aspects of smoking, and were more 

likely to consider smoking socially. 

For many Hispanic youths, adaptation to life in 

the United States may produce psychological stress and 

anxiety. Whether these factors are directly associated 

with smoking among Hispanic youth is not known. In 

a recent study of migrant adolescents in the San Diego, 

California, area, Lovato and colleagues (1994) reported 

that respondents’ level of acculturation was not related 

to cigarette smoking or alcohol use, even though the 

more acculturated adolescents were more likely to engage in binge drinking. Acculturation remains a strong 

theoretical consideration in smoking initiation, but 

current findings are limited by the methodological 

issues previously cited. In addition, a variety of acculturation measures have been used, and these have 

intrinsic limitations for assessing the cultural learning 

process (Marín 1992). Interpretation is particularly 

problematic when researchers use proxy measures such 

as language proficiency to measure complex psychosocial processes like acculturation. The existence of 

multiple cultures within Hispanic communities adds 

to the complexity of this issue, as is also the case in 

Asian American communities. 

Multiple Group Studies 

Several studies have examined initiation and 

early use of tobacco among more than one racial/ethnic group and have compared data within and among 

these groups. Some of these studies have concentrated 

on analyzing the prevalence of perceived risk factors 

commonly associated with tobacco use, and other studies have addressed the question of what differentiates 

smokers from nonsmokers. 

CDC and 13 universities conducted research in a 

collaborative partnership that involved a series of 

focus groups and in-depth interviews among African 

American, American Indian, Asian American and 

Pacific Islander, Hispanic, and white teenagers. The 

purpose of the research was to assess differences in 

the functional value of smoking, the images associated 

with and social norms that surround smoking, and the 

messages that youths report receiving about smoking. 

The universities used common methodologies, protocols, definitions, and coding schemes for transcripts 

of focus groups and interviews. Preliminary findings 

of this research are that (1) young smokers know about 

the addictive nature of nicotine; (2) smoking is viewed 

as “cool” and “grown up”; (3) smoking derives functional value from group belonging and stress 

management; (4) among girls, notions of “respect” and 

“reputation” are influential for nonsmoking in some 

groups; and (5) parental messages about smoking vary 

by race/ethnicity, but African American and Hispanic 

parents give clearer messages about not smoking than 

parents in other groups. Other emerging issues noted 

in this analysis are that (1) smoking is not seen as image enhancing among African American girls; 

(2) African Americans were more likely to pair cigarette smoking with marijuana to maintain a “high”; 

(3) parental smoking is a negative influence, particularly among American Indian families; and (4) variation exists among the racial/ethnic groups with regard 

to the media channels through which messages are 

received (Mermelstein et al. 1996). 

Prevalence of Risk Factors for Cigarette Use 

Several studies have analyzed how possible risk 

factors for tobacco use differ among youths in various 

racial/ethnic groups. For instance, in a study of Los 

Angeles County students in grades seven through 

Factors That Influence Tobacco Use 229 
230 Chapter 4 

Surgeon General’s Report 

nine, Maddahian and colleagues (1986) found that 

African American adolescents reported having the 

highest number of friends who provided cigarettes, 

followed by white, Hispanic, and Asian American adolescents. Perceived ease in acquiring cigarettes was 

highest among white adolescents and lowest among 

Asian American adolescents; Hispanic and African 

American adolescents reported moderate ease in acquiring cigarettes. In assessing how earned income 

vs. allowance income related to cigarette use, the researchers found that Asian American and white adolescents reported having a higher earned income than 

adolescents in the other two racial/ethnic groups; in 

comparison, Hispanic and African American adolescents reported receiving more allowance income than 

Asian American or white adolescents. Maddahian and 

colleagues (1988) subsequently found that African 

American and Hispanic youths reported greater intention to use cigarettes than white and Asian American 

youths. In a more recent study, involving northeastern U.S. youths in grades six through eight, 

Vanderschmidt and colleagues (1993) found that physical violence and sexual activity were the risk behaviors most highly associated with smoking among 

African American, Hispanic, and white students. 

Smoking-related perceptions and risk factors 

also differ among older youths of different racial/ 

ethnic backgrounds. In a study of high school seniors 

Table 1. High school seniors’ perceptions about the risks associated with cigarette smoking, Monitoring the 

Future surveys, United States, 1980–1989 

African 

Americans 

% N* 

American 

Indians 

Perceived risks Gender % N* 

Percentage who believe that people 

take a great risk of harming themselves if they smoke one or more 

packs of cigarettes per day 

Male 68.4 1,586 52.5 221 

Female 71.0 1,901 63.5 181 

Percentage who believe that people 

disapprove or strongly disapprove 

of people aged 18 years and older 

smoking one or more packs of 

cigarettes per day 

Male 77.6 1,717 64.1 220 

Female 80.4 2,076 63.1 210 

Percentage who think their close 

friends disapprove or strongly 

disapprove of their smoking one 

or more packs of cigarettes per day 

Male 75.4 1,193 65.2 179 

Female 80.5 1,610 69.1 155 

Percentage who report that none vs. 

most or all of their friends smoke 

cigarettes

 None Male 17.1 1,340 12.8 200 

Female 19.9 1,807 11.0 184

 Most or all Male 19.0 1,340 30.0 200 

Female 18.7 1,807 36.8 184 

*The number of respondents (N) varied for each question. Each of the numbers (N) reported represents the 

total number of students who were asked a particular question, not the number of students who responded 

affirmatively. 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

participating in the MTF between 1980 and 1989, 

Wallace and Bachman (1993) found that American Indians, both males and females, were less likely than 

students in other racial/ethnic groups to perceive that 

smoking one or more packs of cigarettes per day posed 

a great risk to their health (Table 1). The perception 

that friends and people in general disapproved of 

smoking one or more packs of cigarettes per day was 

least prevalent among male and female American 

Indian high school seniors and most prevalent among 

female Asian American seniors. Finally, the percentage of students who reported that most or all of their 

friends smoked cigarettes was highest among American Indian seniors and lowest among Asian American 

seniors. 

Factors Associated with Initiation of Cigarette Use 

Numerous researchers have assessed patterns of 

cigarette use initiation among young people of various races/ethnicities. For example, Botvin and colleagues (1994) studied potential predictors of cigarette 

smoking onset among seventh graders in six New York 

schools within low-socioeconomic communities. Approximately 50 percent of the children were African 

American, and 36 percent were Hispanic. Statistically 

significant predictors for ever smoking included the 

absence of one or both parents, low grades in school, 

high prevalence of smoking among friends, and a sense 

of hopelessness. The data were not analyzed separately by race/ethnicity. 

Asian 

Americans 

% N* 

67.6 309 69.7 456 66.2 228 64.0 11,266 

71.8 307 67.1 477 64.2 241 66.6 11,764 

Mexican 

Americans

% N* 

Puerto Ricans and 

Latin Americans 

% N* 

Whites 

% N* 

80.4 350 77.3 486 82.7 280 77.1 11,970 

85.6 311 81.2 477 82.2 258 70.0 12,459 

77.0 277 76.3 335 77.1 163 73.1 10,346 

81.7 270 80.2 414 79.0 165 73.6 11,163 

19.1 298 14.3 429 10.9 185 11.6 11,226 

29.6 274 17.2 439 12.4 213 9.9 11,760 

12.8 298 16.9 429 19.5 185 19.3 11,226 

11.4 274 17.4 439 21.9 213 25.4 11,760 

Source: Adapted from Wallace and Bachman 1993. 

Factors That Influence Tobacco Use 231 
 

Surgeon General’s Report 

In assessing differences among racial/ethnic 

groups, Koepke and colleagues (1990) compared 14 potential predictors of cigarette smoking onset among 

seventh- through ninth-grade African Americans, Asian 

Americans and Pacific Islanders, Hispanics, and whites 

from Los Angeles and San Diego, California. The researchers found that most variables were not related to 

smoking onset among any of the racial/ethnic groups, 

and no single factor was a statistically significant predictor among all four groups. Greater anger increased 

the likelihood of smoking onset for African American 

and Hispanic youths but was unrelated to smoking onset for Asian American, Pacific Islander, and white 

youths. The number of close friends who had tried cigarettes was a significant predictor of smoking onset for 

Hispanic, Asian American, and Pacific Islander youths 

but not for African American or white youths. These 

studies underscore the variability of predictors among 

groups. 

Peer influences also were identified in a study of 

sixth and seventh graders in San Diego. Elder and 

colleagues (1988) found that white girls, African American boys, and Asian American boys who believed that 

a large number of their peers smoked cigarettes were 

more likely to experiment with smoking. When actual continued use of cigarettes was considered, the 

normative belief (that a large proportion of their peers 

smoked) predicted cigarette smoking for Hispanic 

boys and for white boys and girls. These normative 

perceptions were most strongly associated with experimenting with chewing tobacco among white boys and 

girls and Asian American boys. Other studies also 

have found that peer smoking had a significant effect 

on cigarette smoking initiation. Sussman and colleagues (1987), for example, examined predictors of 

cigarette smoking among Southern California adolescents in Los Angeles and Orange Counties and found 

that peer pressure to smoke was not a predictor of 

smoking, although peer cigarette use was a critical 

predictor for Asian Americans, Hispanics, and whites 

(but not for African Americans). In this same study, 

parental pressure to smoke and knowledge of the 

health consequences of smoking were not associated 

with smoking for any group. On the other hand, three 

variables were statistically significant predictors for 

all four groups—general availability of cigarettes, 

difficulty in refusing offers to smoke, and intent to start 

smoking. The strongest predictors of cigarette smoking were different for each racial/ethnic group: for 

white youths, adult and peer models of smoking 

were the strongest predictors; for Hispanic youths, selfimage as a smoker and adult or peer approval of 

smoking were the strongest predictors; for African 

American youths, preference for risk-taking was the 

strongest predictor; and for Asian American youths, 

low self-esteem and poor achievement in school were 

the strongest predictors. 

Castro and colleagues (1987) also found that peer 

smoking behaviors were significantly correlated with 

cigarette smoking among African American, Asian 

American, Pacific Islander, Hispanic, and white teenagers in Los Angeles County. Disruptive family events 

(e.g., number of relocations) were significantly correlated with cigarette smoking among Asian American, 

Pacific Islander, and white youths but not among 

African American and Hispanic youths. In addition, 

law abidance, liberalism, and religiousness were significantly associated with less frequent cigarette smoking among African American, Asian American, Pacific 

Islander, and white youths but were associated with 

more frequent cigarette smoking among Hispanics. A 

more recent study (Landrine et al. 1994) has found that 

although cigarette smoking among peers is a good predictor of cigarette smoking among white adolescents, it 

is a less powerful predictor of cigarette smoking among 

African Americans, Asian Americans, and Hispanics. 

The role of personal psychological characteristics in predicting cigarette smoking has also been studied in a multiracial/multiethnic setting. Among 

seventh graders in New York City, Bettes and 

colleagues (1990) found that certain psychosocial 

variables—negative self-esteem, positive self-esteem, 

psychological distress, psychological well-being, and 

risk-taking—had no differential effect on tobacco use, 

except that psychological well-being and high risktaking were found to be particularly protective for 

African American seventh graders. 

Factors Associated with Initiation of Smokeless 

Tobacco Use 

Riley and colleagues (1991) found that among 

African Americans, American Indians, and whites, selfreported use of smokeless tobacco was associated with 

the perceived consequences of use, the use of alcoholic 

beverages and cigarettes, peers’ use of smokeless tobacco, beliefs about the health consequences of smokeless tobacco use, and level of perceived control over 

one’s own health. The strongest predictors for all 

groups were previous use of alcoholic beverages and 

tobacco and peers’ use of smokeless tobacco. Perceived 

negative consequences were considered most important among American Indians and whites. For African Americans and American Indians, the strongest 

predictor of the amount of smokeless tobacco used was 

previous use of alcoholic beverages and cigarettes. For 

232 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

whites, the strongest predictor of the amount of smokeless tobacco used was peers’ use of smokeless tobacco. 

Summary, Initiation and Early Use of Tobacco 

The limited number of studies renders the results 

fragmentary, but some general findings emerge. 

Certain categories of variables—sociodemographic, 

environmental, behavioral, personal, and psychological—may be related to tobacco use initiation and continued use among youths of various racial/ethnic 

minority groups. Some of these categories of variables 

may predict initiation of tobacco use for all people, 

regardless of their race/ethnicity (USDHHS 1994), but 

the predictive strength of these variables likely differs 

across racial/ethnic groups. Because of the methodological problems previously mentioned, the summarized findings are not comparable across racial/ 

ethnic groups; these findings are meant to suggest a 

pattern rather than to convey a body of evidence. 

Future research must establish the strength of various 

predictors by using comparable and culturally appropriate measurements. In addition, several important 

predictors of tobacco use among racial/ethnic youth 

and the environmental factors surrounding it have not 

been thoroughly researched. One such example is the 

role of tobacco advertising, which has been shown to 

affect a number of risk factors related to smoking initiation, such as perceptions about the pervasiveness 

of cigarette smoking, its social acceptability, its danger, and its function in social situations (USDHHS 

1994). Finally, the relative strength of a community’s 

tobacco control infrastructure may influence behaviors and policies about tobacco and the tobacco industry. Robinson and colleagues (1995) suggested that this 

fact should be considered in assessments of initiation 

and early use of tobacco products. 

Tobacco Use Among Adults 

The factors associated with tobacco use among 

adult members of racial/ethnic groups have been studied even less than those among young people. Few 

studies have analyzed tobacco use among adult American Indians, Alaska Natives, Asian Americans, or 

Pacific Islanders, and only limited information is available on predictors of continued tobacco use among 

African Americans and Hispanics. 

African Americans 

Romano and colleagues (1991) examined the 

association between cigarette smoking, social support, 

and stress in a sample of adult African Americans in 

the San Francisco and Oakland areas of California. 

African American men and women who reported high 

levels of stress were more likely to smoke than those 

reporting fewer stressful conditions. The role of stress 

in cigarette smoking among adult African Americans 

also has been supported by the findings of Feigelman 

and Gorman (1989) and Ahijevych and Wewers (1993). 

In a national sample of adults interviewed for the 1987 

General Social Survey, Feigelman and Gorman (1989) 

found that the highest proportion of smokers were 

African Americans who were exposed to high levels 

of stress and who had a low level of occupational prestige. In comparison, whites with low stress and high 

occupational prestige had the lowest proportion of 

smokers. African American women with underdeveloped social networks were also more likely to smoke 

than those with strong social support. The role of social support was not statistically significant for African American men. In fact, African American men who 

appeared to have little emotional support from friends 

or family were less likely to smoke than African American men who had such support. 

American Indians and Alaska Natives 

Hodge and colleagues (1996) studied adult 

American Indian patients in Northern California. The 

sample included members of the Hupa, Maidu, Pit 

River, Pomo, and Yurok Tribes of California as well as 

a number of Sioux Indians. The researchers found few 

differences in the type and amount of social support 

experienced by American Indian smokers and nonsmokers. In the urban areas of San Francisco and San 

Jose, American Indians who reported high levels of 

stress were more likely to be current smokers than 

those who reported lower levels of stress. American 

Indians living in urban areas also reported being more 

motivated to quit than those in rural areas. 

In a study of 614 American Indian women (Eastern Band Cherokee) in western North Carolina, 

Spangler and colleagues (1997) found several correlates with higher prevalence of current smoking, including younger age, alcohol use, no yearly physical 

examination, marital status of separated or divorced, 

lack of friends, and lack of church participation. 

Having a lower level of education and having consulted an Indian healer were correlated with higher 

smokeless tobacco use. 

Factors That Influence Tobacco Use 233 
 

Surgeon General’s Report 

Asian Americans and Pacific Islanders 

In a study of adult male Vietnamese refugees living in the San Francisco area, Jenkins and colleagues 

(1990) found that cigarette smoking was significantly 

related to having immigrated to the United States 

within the previous nine years, not knowing that smoking causes cancer, having an income below the federal 

poverty level, and having limited proficiency in 

English. No significant associations were found 

between men’s cigarette smoking and education, 

alcohol use, marital or employment status, health condition, or age. In another study, conducted between 

1989 and 1991 (CDC 1992), cigarette smoking among 

Chinese, Vietnamese, and Hispanics in California was 

associated with an annual income of less than $25,000, 

a high school education or less, recent immigration to 

the United States, and limited proficiency in English. 

In a survey of Southeast Asian men—primarily 

Cambodian, Laotian, and Vietnamese—Chen and colleagues (1993) found that compared with former smokers and persons who had never smoked, smokers were 

more likely to have limited proficiency in English, to 

be more traditional (less acculturated), and to report 

that almost all of their five best friends were smokers. 

Only about one-third of the men surveyed had heard 

that cigarette smoking may cause heart disease. In 

addition, Chen and colleagues observed no statistically 

significant differences in the knowledge of smoking 

danger reported by smokers, former smokers, or persons who had never smoked. 

In a survey of 832 Cambodian, Vietnamese, and 

Laotian men in Ohio, Moeschberger and colleagues 

(1997) found that the odds of never smoking and of 

being a former smoker were significantly higher 

among men who were employed than among those 

unemployed. In addition, current smokers were more 

likely than nonsmokers to be traditional or bicultural, 

whereas men who had assimilated into U.S. culture 

were four times as likely to have quit. 

Hispanics 

The literature on correlates of cigarette smoking 

among Hispanic adults is more substantive than that 

for the other racial/ethnic minority groups. These 

studies permit exploration of the interaction of cultural 

pride and acculturation with other correlates of cigarette smoking (Marín et al. 1989a; Castro et al. 1991) 

and drug use among Hispanics (see Chapter 2). 

The possible relationship between symptoms of 

depression and cigarette smoking was investigated by 

Pérez-Stable and colleagues (1990), who examined the 

association between smoking status (i.e., current smokers, former smokers, and those who had never smoked) 

and depressive symptoms in a random sample of 551 

Hispanics in San Francisco. After controlling for gender, acculturation, age, education, and employment 

status, significant differences in depression (as measured by the Center for Epidemiological Studies Depression [CES-D] Scale) remained between current 

smokers and nonsmokers (both former smokers and 

lifetime abstainers). Current smokers had a 70 percent greater risk for having depressive symptoms than 

persons who had never smoked. A recent study that 

used data from the HHANES identified an association 

between patterns of smoking initiation and depressed 

mood, a history of major depression, or both (Escobedo 

et al. 1996). The belief that cigarette smoking reduces 

tension has been identified as a potent reason for smoking, according to researchers studying Hispanics from 

South America and the Caribbean who live in the New 

York City area (Larino et al. 1993), as well as Mexican 

Americans in San Francisco (Marín et al. 1989a). 

To identify additional correlates of tobacco use 

among adult Hispanics, Lee and Markides (1991) compared three age groups of adults in a sample of Mexican Americans in the Southwestern United States who 

were interviewed between 1982 and 1984 as part of 

the HHANES. Among Mexican Americans aged 

20–39 years, being a smoker was associated with the 

increased consumption of alcohol for both men and 

women, with poorer health for men, and with more 

depressive symptoms for women. Among Mexican 

American men aged 40–59 years, those who smoked 

cigarettes also consumed more alcohol than those who 

did not smoke. Among Mexican American women 

aged 40–59 years, those who smoked cigarettes also 

consumed more alcohol and had lower diastolic blood 

pressure, lower body mass, and more depressive 

symptoms than those who did not smoke. Among 

Mexican Americans aged 60–74 years, men who 

smoked were more likely to consume alcohol and coffee and to have lower body mass than men who did 

not smoke; women who smoked were also more likely 

to consume coffee and alcohol than those who did not 

smoke. A Mexican American subsample of the 

HHANES showed that cigarette smoking was associated with the presence of other smokers at home or at 

the workplace and with the respondent’s level of 

acculturation (Coreil et al. 1991). These data also 

showed that cigarette smoking status was not related 

to educational level or to employment status but that 

age was positively associated with the number of 

cigarettes smoked per day among younger men and 

women aged 20–39 years. A study of Hispanic 

adults in New Mexico (Samet et al. 1992) found a relationship between low levels of formal education and 

234 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

prevalence of cigarette smoking. Low socioeconomic 

status, often indicated by education, was also related 

to cigarette smoking in that study. 

A number of studies conducted in San Francisco 

have compared the psychosocial characteristics of Hispanic smokers with those of white smokers. These 

studies provided an understanding of culture-specific 

differences in attitudes, norms, and expectancies of 

smokers and served as the basis for developing a 

culturally appropriate smoking cessation intervention—Programa Latino Para Dejar de Fumar (Hispanic 

Program to Quit Smoking) (see Chapter 5). In one such 

study (Marín et al. 1990a), Hispanic smokers were significantly more concerned than white smokers about 

harming their children’s health. White smokers, 

on the other hand, were significantly more concerned than Hispanic smokers about burning holes in 

their clothes and feeling controlled by the need to 

smoke. White smokers were more likely than Hispanic 

smokers to view other smokers as friendlier and more 

sociable, aggressive, attractive, and feminine than nonsmokers (Marín et al. 1989b). More acculturated 

Hispanics provided responses that more closely 

resembled the responses of whites than the responses 

of less acculturated Hispanics (Marín et al. 1989b). 

Acculturation also was found to affect an individual’s 

willingness to quit smoking on the basis of advice from 

his or her parents and physicians. Similarly, in a New 

York City area survey of 88 Hispanics who expressed 

interest in quitting cigarette smoking, Mahony and 

colleagues (1993) found that their reasons for smoking differed by their level of acculturation. 

Summary, Tobacco Use Among Adults 

A few variables have been associated with the 

continued use of cigarettes among adults from racial/ 

ethnic groups. Cigarette smoking among members of 

the four racial/ethnic groups seems to be associated 

with depression, psychological stress, and environmental factors such as tobacco advertising and promotion and the influence of peers who smoke. The 

high levels of stress among members of the four 

racial/ethnic groups may be the product of such factors as low-prestige jobs; poverty; difficulties associated with living in a new environment or culture; 

limited proficiency in English; prejudice and discrimination; pressures to acculturate; limited free time; and 

multiple demands on time related to jobs, substandard 

housing, and the care of small children. Smoking cessation programs directed at members of these racial/ 

ethnic groups should address stress reduction in 

the same way that tobacco prevention and control strategies should consider the historical context of tobacco 

and the tobacco industry in the community and 

cultural differences among racial/ethnic minority 

communities. 

These data also indicate that Hispanic smokers 

have expectations and attitudes related to cigarette 

smoking that differ from those of white smokers—a 

finding that supports the need for culturally appropriate cessation interventions. Future studies should 

determine if similar differences in expectancies and 

attitudes exist among smokers of the other three 

racial/ethnic groups considered in this report. The 

limited data available support the need for more and 

better designed studies of tobacco use among members of the various racial/ethnic groups. 

Smoking Cessation 

Little is known about the psychosocial factors 

that influence cigarette smoking cessation among 

members of racial/ethnic groups. Although people’s 

level of addiction is an important determinant of 

whether they will successfully stop smoking, limited 

information is available on patterns of addiction 

among members of various racial/ethnic groups. (For 

more information on patterns of addiction, see Chapter 3. For details about other variables that affect smoking cessation, such as smoking patterns and access to 

culturally appropriate cessation services, see Chapters 

2 and 5.) 

African Americans 

Knowledge about the damaging effects of smoking can be an important motivator of smoking cessation (Orleans et al. 1989; Jepson et al. 1991; also see 

Chapter 5). Studies of African Americans’ knowledge 

about the health consequences of tobacco smoking 

have produced contradictory findings. Klesges and 

colleagues (1988), for example, interviewed African 

American and white adults in Fargo, North Dakota, 

and Memphis, Tennessee, and found that proportionately more whites than African Americans knew that 

cigarette smoking was related to heart attacks, emphysema, premature births, and skin wrinkles. Similarly, 

Vander Martin and colleagues (1990) found that African Americans from the San Francisco Bay area who 

smoked cigarettes were less concerned about the health 

effects of cigarette smoking than were whites who 

smoked. African Americans also were less likely to 

believe that cigarettes were addictive, produced harmful health effects, or caused heart attacks. 

Factors That Influence Tobacco Use 235 
 

Surgeon General’s Report 

Conversely, in a 1990 study in St. Louis and Kansas City, Missouri, Brownson and colleagues (1992) 

found that about the same percentage of African Americans and whites believed that smoking was harmful 

to people’s health. Although African Americans 

recognized the harmful effects of environmental tobacco smoke (ETS), they tended to minimize some of 

the health effects of smoking, particularly its link with 

heart disease. Similarly, an ABC News/The Washington Post survey conducted in February 1993 found that 

a large proportion of African American and white 

adults perceived ETS to be a health risk (Roper Center 

for Public Opinion Research 1993). In that poll, however, a greater proportion of African Americans than 

whites reported that they worried a great deal about 

ETS. In studies limited to African Americans, researchers have reported differences based on smoking status. Warnecke and colleagues (1978) interviewed African American women in Buffalo, New York, and found 

that current smokers were less likely to say they believed that cigarette smoking was related to a variety 

of conditions, including cancer and heart disease, than 

were former smokers or persons who had never 

smoked. 

Most African American smokers want to quit, 

and many have tried. In a 1986 study of African American smokers who were policyholders of the North 

Carolina Mutual Life Insurance Company, Orleans and 

colleagues (1989) found that 79.3 percent of respondents had tried to quit smoking at least once in their 

lifetime. Hoffman and colleagues (1989) found that 

most of the patients in a general community hospital 

in Chicago who smoked reported previous attempts 

to quit on their own, and 65 percent wanted to stop 

smoking immediately. More than two-thirds of these 

African American smokers indicated that they would 

like a formal program to help them quit smoking. In a 

more recent survey, Ahluwalia and McNagny (1993) 

found that among all African American patients visiting a county-operated health facility in Atlanta, Georgia during a three-week period, 86 percent of the 

smokers wished to quit. Ninety-nine percent of those 

who wanted to quit smoking indicated they would participate in a smoking cessation program even if it involved visits to the hospital. According to data from 

the 1993 NHIS (CDC 1994b), 71.4 percent of African 

Americans aged 18 years or older who currently 

smoked were interested in quitting. 

Royce and colleagues (1993) used a sample 

drawn from metropolitan communities in California, 

New Jersey, New York, and North Carolina as part of 

the Community Intervention Trial for Smoking Cessation (COMMIT) project and found that more African Americans than whites reported a strong desire to 

quit smoking and more attempts to quit in the past 

year. These researchers also observed that a larger 

percentage of African Americans than whites reported 

a need to smoke within 10 minutes of awakening (a 

behavioral symptom of nicotine dependence), even 

after the analysis controlled for age, education, and 

gender. In the San Francisco Bay area study by Vander 

Martin and colleagues (1990), African American adult 

smokers were more interested in quitting smoking than 

were white adult smokers and were also more confident that they could successfully quit. 

When smoking cessation trends are compared, a 

different pattern emerges by gender. Hahn and colleagues (1990) found a slightly higher proportion of 

white women in Minneapolis and St. Paul (33 percent) 

than of African American women (29 percent) who 

reported trying cigarettes with lower levels of tar and 

nicotine in the previous year, and a higher proportion 

of white men (63 percent) than African American 

men (52 percent) reporting that they had tried to quit 

smoking. 

In their study of African American women in 

Buffalo, New York, Warnecke and colleagues (1978) 

found that many women who had quit smoking 

attributed their quitting to the fact that cigarette smoking causes cancer (44 percent) or other diseases 

(45 percent); to physical side effects such as coughing 

or headaches (36 percent); or to negative cosmetic effects such as bad breath, stained teeth, or bad smell 

(34 percent). More recently, in a series of eight focus 

group discussions with African American women 

smokers residing in Chicago public housing developments, respondents said that quitting was difficult for 

them because they lived in a highly stressful environment that made it difficult to manage their personal 

lives (Lacey et al. 1993). Cigarette smoking was one of 

the few pleasures available to them in such an environment, and the women had few if any sources of 

information on how to quit smoking. In addition, these 

women tended to believe that cigarette smoking posed 

minimal health risks, that the behavior was quite common among other adults, and that all that was needed 

to quit was the willingness to do it. In a study of urban pregnant women, O’Campo and colleagues (1992) 

found that the only predictor of quitting smoking 

during pregnancy for African American women was 

intention to breast-feed, whereas among white women, 

the best predictors were educational level, age, and 

parity. About 46 percent of African American women 

who quit smoking during pregnancy relapsed within 

6–12 weeks after delivery. Formula feeding of the infant was the best predictor of postpartum smoking 

relapse for both African American and white mothers. 

236 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

American Indians and Alaska Natives 

Few studies have focused on smoking cessation 

among American Indians, and no studies have addressed smoking cessation trends among Alaska Natives. In a survey of American Indians in Northern 

California, respondents were found to have fairly high 

levels of information regarding the health effects of 

cigarette smoking (Hodge et al. 1994). For example, a 

similar proportion of urban (94 percent) and rural (91 

percent) American Indian smokers knew that smoking during pregnancy would harm the fetus. Although 

American Indian smokers were as knowledgeable as 

nonsmokers regarding the health effects of cigarette 

smoking, attitudes about smoking differed between the 

two groups. American Indian smokers were more 

likely than nonsmokers to think that it is acceptable to 

smoke and chew tobacco, to permit the advertising of 

tobacco products, to let visitors smoke in one’s home, 

and to allow smoking in restaurants. In addition, 

American Indian women who smoked reported a 

greater number of depressive symptoms (as measured 

by the CES-D) than nonsmoking women. However, 

researchers observed no differences in the number of 

depressive symptoms among men who smoked compared with men who did not smoke. A fairly large 

number of American Indians reported that they were 

not interested in quitting (45 percent of residents in 

urban areas and 55 percent of residents in rural areas). 

In the 1993 NHIS, however, 65.0 percent of American 

Indian or Alaska Native smokers aged 18 years or over 

reported that they wanted to quit smoking cigarettes 

completely (CDC 1994b). In another study of current 

smokers who were patients at Indian health clinics, 

Lando and colleagues (1992) found that the most commonly mentioned reasons for relapse were cravings, 

stress, nervousness, and the pressure to smoke in social situations. 

Asian Americans and Pacific Islanders 

Little has been published about smoking cessation among Asian Americans and Pacific Islanders. In 

one study that addressed this issue, Jenkins and 

colleagues (1990) found that among adult Vietnamese 

refugees living in the San Francisco area, 82 percent of 

smokers wanted to quit, but 71 percent of them felt 

that quitting would be difficult. About 69 percent of 

the Vietnamese smokers had been advised by their 

physicians to reduce or quit smoking. Lack of information about the health consequences of cigarette 

smoking is a problem among some Asian American 

groups. In a study of Chinese Americans in Oakland, 

California, Lew (1992) found that 53 percent of the respondents did not know that heart disease was associated with cigarette smoking, and 26 percent of them 

said they did not know that lung cancer was related to 

cigarette smoking. Of current Asian American or 

Pacific Islander smokers aged 18 years or more in the 

1993 NHIS, 60.2 percent reported being interested in 

quitting smoking completely (CDC 1994b). 

Hispanics 

Several studies have examined what motivates 

adult Hispanic smokers to quit. Marín and colleagues 

(1990b) found that family-related consequences and 

concerns (e.g., to set a good example for one’s children) contributed more to Hispanics’ desire to quit 

smoking than to whites’ desire to quit. Hispanic smokers who intended to quit believed that by doing so they 

would improve family relations, breathe more easily, 

and have a better taste in their mouths. They also believed that they would gain weight. In an earlier study, 

Hispanic smokers who subjectively considered themselves to be highly addicted to tobacco had the lowest 

levels of perceived self-efficacy to avoid cigarette 

smoking (Sabogal et al. 1989). The level of perceived 

self-efficacy to avoid smoking also declined as the reported number of cigarettes smoked per day increased. 

In the 1993 NHIS, 68.7 percent of Hispanic smokers 

aged 18 years or over said they wanted to quit smoking cigarettes entirely (CDC 1994b). Research with 

Hispanic adults has shown that their expectancies for 

quitting and for continued cigarette smoking differ in 

terms of their level of acculturation so that those 

Hispanics who have acculturated more tend to resemble whites in their expectations (Marín et al. 1989a, 

1990b). 

Summary, Smoking Cessation 

Although the literature on predictors or correlates of smoking cessation among members of these 

four racial/ethnic minority groups is limited, an 

important theme emerges from the studies reviewed 

in this section. Some studies, primarily those of African Americans (see also Chapter 5), have shown that 

smokers tend to report having little knowledge of the 

health effects of smoking or techniques to quit smoking. Smokers’ lack of information about cessation 

techniques available in the community is consistent 

with underdeveloped tobacco control infrastructures 

and the low levels of resources for research and 

program delivery (Robinson et al. 1995; Shelton et al. 

1995). Information alone is not enough to produce a 

Factors That Influence Tobacco Use 237 
 

Surgeon General’s Report 

behavior change as complex as quitting, but information on the health consequences of smoking is still 

perceived by some researchers as necessary to develop 

the motivation to quit. Information on resources and 

techniques for quitting may also be essential for the 

success of a smoking cessation program. The lack of 

information may appear surprising in view of the 

decades-long smoking education campaigns conducted 

by federal and state agencies and voluntary associations, 

but it is consistent with the thesis that resources allocated for tobacco control research and programs have 

been proportionately lower in racial/ethnic communities than in white communities (Robinson et al. 1995). 

Equally important, information may not have been 

presented through appropriate channels, and the 

motivational messages may not have been culturally 

appropriate (see Chapter 5). 

This literature review has identified several areas for which more appropriate approaches are 

needed. First, the effects of stress and depression on 

attempts to quit smoking are particularly important 

among members of racial/ethnic groups. Culturally 

appropriate cessation interventions need to identify 

the sources of stress and then present stress-reduction 

techniques that are perceived as appropriate and effective by members of racial/ethnic groups. Second, 

group-specific motivations and attitudes predict a 

person’s interest in and success at quitting smoking. 

Future research should focus on group-specific 

attitudes and expectancies as well as those that are 

shared by racial/ethnic groups. The effects of acculturation and group identification also need to be 

addressed, particularly because research involving 

Hispanics has shown that acculturation plays an important role in shaping the attitudes and expectancies 

held by Hispanic smokers (Marín et al. 1989a; 1990a,b). 

In summary, the distinctive psychosocial environment of disparate racial/ethnic minority groups 

requires that additional tailored intervention materials be designed. Existing smoking cessation programs 

and strategies currently designed for the general population cannot simply be adapted or translated for use 

with a particular racial/ethnic group (see Chapter 5 

for more discussion of cessation). 

Methodological Limitations of 

the Literature 

The content of the literature must be interpreted 

in light of its methodological limitations. The weaknesses of the studies demand caution, but on a more 

positive note, they suggest appropriate directions for 

future research. These limitations fall into four main 

categories: (1) nongeneralizability, (2) noncomparability, (3) sample size and aggregation problems, and 

(4) nonreporting. 

Nongeneralizability. Most studies of psychosocial 

factors in racial/ethnic groups have been conducted 

in big cities such as Chicago, Los Angeles, New York, 

and San Francisco. Some of the findings may not apply to persons residing in smaller cities or rural areas 

where the psychosocial environment that influences 

tobacco use may differ from that in large urban areas 

or racial/ethnic enclaves in large cities. 

Similarly, primary prevention research in this 

field has relied heavily on urban school populations. 

Most studies have excluded school dropouts; students 

attending alternative, parochial, or private schools; 

those housed in detention facilities; those living 

and working in rural environments; and other 

at-risk youths, and therefore may have limited 

generalizability. 

Noncomparability. Many studies have used different variables to measure the same phenomenon, or 

they have measured the same variables differently. 

Differential instrumentation (Cook and Campbell 

1979) is a problem because a construct may not only 

differ in meaning from one culture to another, but its 

appropriate measurement (operationalization) may 

also differ (Berry 1969; Triandis and Marín 1983; Marín 

and Marín 1991). For example, if a risk factor survey 

initially developed for a white population is administered unchanged to African Americans or Hispanics, 

it may prove to be culturally inappropriate and invalid. 

Instead, researchers should consider what meanings 

the survey terms or constructs have for the group 

members (Brislin et al. 1973). Few researchers have 

conducted the basic ethnographic and psychosocial 

research needed to identify these culture-specific constructs. With the exception of some investigators who 

have studied smoking cessation among Hispanics 

(discussed earlier in this chapter), most researchers 

have ignored a central assumption of cross-cultural 

research—that equivalent and culturally appropriate 

instrumentation must first be developed and used. 

Another difficulty in analyzing and comparing 

studies of tobacco use among young respondents is 

that the studies rarely measure comparable behaviors. 

For example, some researchers attempt to predict the 

first instance when a person uses a tobacco product. 

Other researchers, primarily in cross-sectional 

studies, use their data to predict current reported tobacco use and assume that those variables may help 

explain initiation of tobacco use. 

238 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Aggregation problems. A common problem with 

some of the studies reviewed in this chapter is that 

racial/ethnic populations have not been assessed 

separately from larger populations. For example, some 

studies of African Americans and whites have failed to 

separate these groups when reporting the results. Other 

studies, particularly those with small sample sizes, have 

not separated subgroups within racial/ethnic minority groups—for example, distinguishing Chinese from 

Vietnamese—even when such separation is essential to 

properly understanding the results. Such results would 

be difficult to reproduce without knowledge of the 

population mix. 

Nonreporting. The data summarized in this 

chapter are further limited by a bias in the reporting 

of results. Some researchers report only significant results and fail to indicate the equally important obserChapter Summary 

vation that some associations are not significant. This 

limitation can negatively affect the design of culturally appropriate prevention strategies. In addition, few 

of the studies reviewed in this chapter adequately describe the procedures followed or the data collected. 

Properly understanding the meaning and measurement of many of the variables included in these 

research reports is difficult because of the paucity of 

detail. Finally, few of these studies have reported on 

issues of statistical power in their designs, which frequently are characterized by a small sample and a large 

number of variables. 

Despite such limitations in the quality and comparability of data, these studies identify the variables 

that should be the focus of future research and 

variables that need to be considered in culturally 

appropriate prevention programs (see Chapter 5). 

Tobacco use patterns are influenced by many 

factors. In addition, the factors themselves and their 

importance in influencing tobacco use vary among racial and racial/ethnic groups. Some common experiences and themes, however, emerge: the targeted 

advertising and promotions through racial/ethnicspecific media channels, the influence of peers who 

smoke on initiation of tobacco use, the association of 

depression and stress with cigarette smoking and cessation among adults from different racial/ethnic 

groups, and the influence of acculturation. Psychosocial variables help explain individual tobacco use 

behavior. Tobacco advertising and promotion are 

influential because they appear to affect the perceived 

sense of pervasiveness, function, and image of tobacco 

use, which in turn affect these psychosocial variables. 

Another possible influence is the historical relationship between racial/ethnic minority communities and 

the tobacco industry. Most likely, it is not any one 

single factor but the interplay or convergence of these 

factors that significantly influences both a person’s decision to use tobacco and the resulting tobacco use patterns. The effects of each factor have so far eluded 

quantification by researchers based on available evidence; more research is needed to better understand 

the etiology, exposure, and effects of these factors. 

Factors That Influence Tobacco Use 239 
 

Surgeon General’s Report 

Conclusions 

1.	 The close association of tobacco with significant 

events and rituals in the history of many racial/ 

ethnic communities and the tobacco industry’s 

long history of providing economic support to 

some racial/ethnic groups—including employment opportunities and contributions to community groups and leaders—may undermine 

prevention and control efforts. 

4. Although much of the original research on psychosocial factors that influence tobacco use reflects 

general processes that may apply to racial/ethnic 

populations, documenting such generalizability 

requires further research. 

5. The initiation of tobacco use and early tobacco use 

among members of the various racial/ethnic minority groups seem to be related to numerous categories of variables—such as sociodemographic, 

environmental, historical, behavioral, personal, 

and psychological—although the predictive power 

of these categories or of specific risk factors is not 

known with certainty because of the paucity of 

research. 

2.	 The tobacco industry’s targeted advertising and 

promotion of tobacco products among members 

of these four U.S. racial/ethnic groups may undermine prevention and control efforts and thus 

lead to serious health consequences. 

3.	 The high level of tobacco product advertising 

in racial/ethnic publications is problematic because the editors and publishers of these publications may omit stories dealing with the damaging 

effects of tobacco or limit the level of tobacco-use 

prevention and health promotion information included in their publications. 

6. Cigarette smoking among members of the four 

racial/ethnic groups is associated with depression, 

psychological stress, and environmental factors 

such as advertising and promotion and peers who 

smoke, as is also the case in the general population. The role of these factors in tobacco use among 

members of these racial/ethnic groups deserves 

attention by researchers and persons who develop 

smoking prevention and cessation programs. 

Appendix. A Brief History of Tobacco Advertising 

Targeting African Americans 

A previous report of the Surgeon General 

(USDHHS 1994) presented a brief historical perspective of cigarette advertising in the United States 

focusing on advertising strategies targeting youths. 

Because targeted marketing to other racial/ethnic 

groups is a more recent phenomenon and because information about this practice with African Americans 

is more available, this appendix focuses on advertising to African Americans. This appendix updates the 

review in the 1994 Surgeon General’s report, particularly as it relates to African Americans. 

Early Assumptions 

A significant proportion of cigarette advertising 

targeting African Americans was based on the belief 

that consumer behavior among African Americans 

differs from that of whites. In the 1950s, a primary 

belief of advertising agencies working on cigarette 

advertising was that status-seeking was a central motivator of African Americans. A survey of Ebony readers, published in Advertising Age (1950), showed that 

“prestige and quality—not cost—are the most important factors to stress when appealing to colored 

buyers. Because of the psychological considerations 

involved, Negroes are extremely desirous of being 

identified as customers who recognize and demand 

quality merchandise” (p. 17). 

Another early assumption of advertising agencies targeting African Americans was that advertisements featuring African American models were more 

effective—or at least more appealing to African 

240 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Americans—than advertisements portraying whites. 

In a 1950 survey of the buying habits and motivations 

of African Americans, Starch and colleagues found that 

the majority of Ebony readers preferred advertisements 

featuring African American models, although about 

one-third of the African American respondents said 

that it did not matter whether African American models were used (Advertising Age 1950). In a later study 

of consumer reactions to the use of white or African 

American models, 93 white and 88 African American 

college freshmen in Houston were asked to react to 

four cigarette advertisements, indicating whether the 

models were ugly or beautiful, low class or high class, 

and friendly or unfriendly (22 bipolar scales were presented) (Barban and Cundiff 1964). In general, the cigarette advertisement with white models and the same 

advertisement with African American models drew 

similar reactions from whites and African Americans. 

In a more recent study, however, African Americans 

who strongly identified with their culture were more 

likely to prefer African American models (Whittler 

1989). Another recent study has shown that African 

American college students preferred television commercials for consumer products that included African 

American models (Pitts et al. 1989). These findings 

were replicated recently among African American 

Chicago youths aged 12–14 years who perceived African American models in cigarette advertisements as 

more appealing (Huang et al. 1992). 

A central belief related to targeted advertising 

and marketing is the assumption that members of racial/ethnic groups, particularly African Americans and 

Hispanics, are brand-conscious and brand-loyal consumers. This approach to purchasing is believed to 

motivate consumers to spend extra money to purchase 

a product with a recognized brand name or a product 

that has been used by family members and neighbors 

for a relatively long period of time. Large multinational brand names often are associated with quality 

in the immigrants’ countries of origin, and purchasing of those brands in the United States may serve as 

an example of having “arrived” or achieved a soughtafter economic status. Other researchers hypothesize 

that previous consumer experiences and an increase 

in disposable income produce brand consciousness. 

For example, Dallaire (1955) argued that “the Negro’s 

desire to improve his lot, his increasing income and 

the fact that he’s been burned so badly and so often in 

the past with shoddy merchandise makes him a highly 

brand-conscious consumer” (p. 58). Whether brand 

loyalty is indeed a characteristic of certain racial/ethnic minority groups continues to be debated 

(Deshpande et al. 1986; Donthu and Cherian 1992); 

however, this assumption often has been invoked in 

the design of advertising directed at members of 

racial/ethnic groups. 

Promotional campaigns directed at African 

Americans and members of other racial/ethnic groups 

also operate under the assumption that these individuals are more likely than whites to trust advertising, 

although most of the studies on which this perception 

is based have been limited by methodological flaws 

such as nonrandom sampling and a small sample size. 

In a 1961 study of 1,106 African Americans and 537 

whites, about twice as many whites as African Americans had unfavorable attitudes toward all types of 

advertising (Bullock 1961). In a 1968 study of 1,846 

persons, the 77 African Americans interviewed had the 

highest proportion (53 percent) of favorable responses 

to the open-ended question “How do you yourself feel 

about advertising?” compared with 1,707 whites (40 

percent) (Bauer and Greyser 1968). Eleven years later, 

Durand and colleagues (1979) interviewed 80 persons 

and found that African Americans were consistently 

more trusting of television and newspapers than 

whites were, and they relied less on magazine advertisements. Soley and Reid (1983) interviewed a random sample of 185 Atlantans and found that African 

Americans were more satisfied with the informational 

value of magazine and television advertising than 

whites were and that high-income respondents were 

the least satisfied with advertising. 

Early Targeted Advertising Efforts 

(1940s–1960s) 

Turn-of-the-century advertisements for tobacco 

products tended to include women, to emphasize female sexuality, and to portray women as dangerous 

and delightful. Conversely, American Indians and 

African Americans often were pictured as childlike and 

unattractive (Mitchell 1992). Tobacco companies have 

depicted African Americans in their advertisements 

since the first Bull Durham advertisements appeared 

at the turn of the century, but only since the 1940s have 

they aggressively targeted African Americans as a distinct consumer market. 

In the decades that have followed, tobacco companies have been described as “bold pioneers in both 

their use of new media and their targeting of other 

segments even when controversial” (Pollay et al. 1992, 

p. 49). In 1942, the advertising agency of the Lorillard 

Tobacco Company, J. Walter Thompson Company, began to monitor cigarette sales in African American 

neighborhoods as part of an Old Gold cigarette 

promotion (Pollay 1988). By 1948, Philip Morris was 

Factors That Influence Tobacco Use 241 
 

Surgeon General’s Report 

running its “no cigaret hangover” campaign in the 

African American press and in daily newspapers published in languages other than English (Tide 1948, 

p. 18). By 1955, several cigarette companies, including Philip Morris, were producing advertising materials targeting African Americans and Hispanics 

(Printers’ Ink 1955). Soon thereafter, Philip Morris 

began placing point-of-sale materials in English as well 

as Spanish for the newly repositioned Marlboro cigarettes (Ullman Gravure, Inc. 1957). A decade after 

tobacco firms first displayed an interest in African 

American consumers, the firms were described as 

“leaders among advertisers gunning for a bigger share 

of the Negro market” (Dallaire 1955, p. 58). 

One of the earliest targeting efforts, conducted 

on behalf of Liggett & Myers’s Chesterfield cigarettes, 

targeted African Americans via advertisements featuring athletes’ testimonials and placed in racial/ethnic 

newspapers and magazines, such as Ebony, Our World, 

and Tan. The company also launched an extensive 

point-of-sale advertising campaign featuring African 

American sports figures (Dallaire 1955). The campaign 

included a series of six documentary films that presented African American achievements. Each film was 

viewed by about 3 million people in 500 primarily 

African American theaters. These films also were 

shown at more than 100 African American colleges, 

where free cigarette samples were distributed, reaching an estimated 900,000 additional people. The success of this effort led to the filming of 13 five-minute 

films featuring interviews with African American 

celebrities (Dallaire 1955). 

The 1950s also marked the introduction of mentholated cigarettes. Although a greater proportion of 

African Americans now smoke mentholated cigarettes 

compared with members of other racial/ethnic groups 

(Chapter 2), no evidence exists that the menthol market was initially conceived as having any special appeal to African Americans or other racial/ethnic 

groups. Mentholated cigarettes are relative newcomers to the tobacco market, and they have been well received by smokers. In 1956, Brown & Williamson’s 

mentholated and then unfiltered Kool cigarette 

enjoyed an increasing market share that attracted its 

competitors to introduce mentholated cigarettes with 

filters. These competitors and their entries included 

R.J. Reynolds’s Salem, Philip Morris’s Spud, Liggett 

& Myers’s Oasis, and Lorillard’s Newport cigarettes. 

By the end of 1957, 5 percent of all cigarettes consumed 

were mentholated, representing “a relatively sharp 

gain for a fledgling cigarette movement exploring a 

new taste” (Wootten 1957, p. 22). 

By 1959, The American Tobacco Company, the 

only firm without a mentholated cigarette, was 

preparing to market a cigarette tentatively called Richmond. The campaign concept allegedly argued that 

the Richmond cigarette “gives you all of smoking’s 

pleasure, with none of its penalties” (Printers’ Ink 1959a, 

p. 12). Around the same time, Brown & Williamson 

was ready to test market a second menthol brand, 

Belair, and was introducing three other menthol brands 

into the market—Riviera, Spring, and Alpine (Printers’ Ink 1959c). Tobacco companies also were beginning to use technical jargon to market their menthol 

products. For example, in 1959, advertising professionals described R.J. Reynolds’s advertisements for Salem 

as “breathlessly reporting ‘an amazing new development’ in copy that was both opaque and studded with 

scientific jargon” to inform consumers about the highly 

porous paper that “air softens every puff. There are, 

obviously, just no limits to the company’s tender regard 

for the smoker” (Printers’ Ink 1959b, p. 8). 

In a study of early cigarette advertisements 

targeting African Americans, investigators compared 

a complete set of cigarette advertisements from Ebony 

for the years 1950–1965 with a matched set of advertisements from Life (Pollay et al. 1992). The results, 

which follow, are important in promoting a better understanding of the principles followed in advertising 

targeted to African Americans. 

By 1965, all six major U.S. cigarette firms had 

advertised in the pages of Ebony as well as Life. While 

the cigarette advertising in Life increased over the 

years, particularly between 1963 and 1965, the amount 

of such advertising in Ebony more than tripled during 

the same period. Ebony initially had fewer cigarette 

advertisements (16 in 1950) than Life (31 in 1950), but 

a dramatic increase in efforts targeting African Americans soon led Ebony to have more than twice the number of cigarette advertisements (57 in 1962) as Life (28 

in 1962) (Pollay 1990; Pollay et al. 1992). An analysis 

of the page costs indicated that this pattern was not 

related to the relative costs of the two magazines nor 

was it likely related to cigarette firms’ joining other 

firms to offer their products to African Americans 

through African American-owned media. Although 

this was a period of general growth for Ebony, “cigarette firms increased their spending and page acquisition even more than the average, keeping themselves 

out in front of the pack” and making cigarette firms 

the source of an estimated 6.5 percent of Ebony’s total 

advertising income in 1962 (Pollay et al. 1992, p. 54). 

The investigators also found that the manifest 

race/ethnicity of the models portrayed in cigarette 

242 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

advertisements increased between 1950 and 1965. Out 

of the 540 cigarette advertisements in Ebony, more than 

84 percent featured identifiable human models, and 

more than 90 percent of those used African American 

models. In the early 1950s, the white endorsers who 

occasionally appeared in Ebony included physicians 

who claimed “more doctors smoke Camels” and television and movie stars (Pollay et al. 1992). Since 1958, 

virtually all models in Ebony’s cigarette advertisements 

have been African American. Yet none of the African 

American cigarette endorsers appearing in Ebony advertisements have appeared in Life advertisements, not 

even the widely popular sports stars and musicians. 

During the early years of targeted advertising, 

professional athletes were most often featured in 

cigarette advertisements. Sports stars were used in 

advertisements even when the advertising copy was 

inconsistent with athletics. A Lucky Strike cigarette 

advertisement in Ebony, for example, referenced scientific tests in 1950 but showed a picture of an African 

American Olympic athlete. These advertisements 

sometimes differed from advertisements appearing in 

media targeting the general population. In 1960, Kent 

cigarettes illustrated its “scientist’s choice” campaign 

in Ebony with another Olympic champion, not with a 

scientist as was done in the advertisement placed in 

Life. Although athletes also appeared in cigarette appeals to the larger public, “cigarette ads aimed at black 

readers of Ebony were significantly more likely to use 

athletes than those aimed at white readers of Life. For 

1950–1965, endorsements from athletes were about five 

times more common in Ebony than in Life” (Pollay et 

al. 1992, p. 51). 

Although most tobacco-producing companies 

were targeting the African American market through 

Ebony, these companies advertised significantly fewer 

cigarette brands in Ebony than in Life (Pollay et al. 1992). 

Advertising of new products seems to have lagged in 

African American publications. Whereas advertisements for filtered tobacco products first appeared in 

Life in 1953 and made up one-half of all cigarette advertising in Life by 1955, advertisements for filtered 

tobacco products did not appear in Ebony until 1955 

and did not represent one-half of its cigarette advertising until 1958, three years later than for Life. 

Recent Targeted Advertising Efforts 

(Late 1960s–1980s) 

By the late 1960s, with racial/ethnic pride enhanced by the success of the civil rights movement, 

the nature and appeal of advertising began to change 

to better tailor the contents of the advertisements 

to targeted racial/ethnic groups. In an analysis of advertisements for all consumer products in selected issues of Ebony and Life in 1960, Berkman (1963) found 

that in about two-thirds of the advertisements featuring models, African American models were substituted 

for white models in advertisements placed in Ebony, 

although the content of the advertisements was basically identical. The African American models initially 

featured were predominantly light skinned, according to Berkman (1963), but subsequent studies of all 

Ebony advertisements between 1952 and 1968 showed 

that the use of male models with more African American features and hair texture became more common 

over time, whereas the advertisements continued to 

use female African American models with Caucasian 

features (Gitter et al. 1972; Weiss 1972). 

Cigarette advertising has changed in similar 

ways. In the late 1960s, Lorillard’s advertisements for 

Kent cigarettes featured an African American model 

wearing an Afro hairstyle and saying “that’s where 

it’s at” (Advertising Age 1968, 1969). By 1971, Liggett 

& Myers employed an advertising agency that specialized in targeting the African American market. The 

agency’s campaign for L&M cigarettes featured a slogan that called the brand “super bad” (meaning excellent), and research indicated the advertisement had 

“great appeal among members of the black community” (Advertising Age 1971a, p. 20). 

Not all cigarette advertisements aimed at African Americans have been successful at employing 

meaningful role models or at credibly using street or 

popular language. One African American marketing 

professional asserted that neither the Marlboro cowboy nor the Viceroy race car driver was meaningful to 

most African Americans and that Winston’s use of the 

phrase “How good it is!” in a racial/ethnic advertisement was a “white man’s cliché that retired with Jackie 

Gleason.” In contrast, Kool’s slogan, “Come all the 

way up to Kool, America’s #1 selling menthol,” was 

lauded for astutely positioning the leader as a sign of 

upward mobility (Wall 1973, p. 71). 

In the 1970s, Liggett & Myers began targeting 

African American women with advertising for its “arty 

female oriented” Eve cigarettes by running advertisements with African American models in Black America 

Magazine, Black Enterprise, Ebony, Essence, Jet, New Lady, 

and Tuesday Magazine (Advertising Age 1971b, p. 24). 

The next year, Liggett & Myers began promoting L&M 

cigarettes to African American men and women via 

advertisements in African American magazines, including Contact, National Scene, and Soul Illustrated 

Factors That Influence Tobacco Use 243 
 

Surgeon General’s Report 

(Advertising Age 1971a). In 1974, Kool cigarette advertisements in African American magazines featuring 

African American models used the copy “Nobody 

makes cool like Kool” (Advertising Age 1974, p. 76). 

During the mid-1970s, products targeted to African Americans began to emerge. For example, R.J. 

Reynolds created an extra-strong menthol product, 

Salem Extra, which was advertised as offering “different smokes for different folks.” The cigarette was 

market-tested in Birmingham and New Orleans 

through outdoor advertisements as well as newspaper and regional magazine advertisements that were 

supported by sampling. These efforts indicated to the 

advertising trade that Salem Extra should be targeted 

to African Americans, along with another extra-strong 

menthol brand, Super M, which was being tested by 

The American Tobacco Company in Pittsburgh 

(O’Connor 1974). 

In the late 1970s, tobacco companies began using billboards to advertise cigarettes in racial/ethnic 

minority communities. Over the past two decades, 

billboards have appeared more frequently in commercially zoned areas and in older, poorer, and otherwise 

less desirable residential neighborhoods that border 

major highways and mass transit systems. In surveys 

of six cities in the late 1980s, Scenic America, a national 

organization opposed to billboards, found far more 

billboards advertising tobacco products in minority 

neighborhoods than in other neighborhoods 

(McMahon and Taylor 1990). For example, 76.7 

percent of advertising messages on billboards in 

one impoverished African American community in 

Philadelphia were for alcoholic beverages and tobacco 

products. In San Francisco, 62 percent of the billboards 

in predominantly African American neighborhoods 

advertised cigarettes, compared with 36 percent of all 

billboards citywide (McMahon and Taylor 1990). According to the Outdoor Advertising Association of 

America Marketing Division, tobacco companies are 

the leading outdoor advertisers, accounting for approximately one-third of all billboards (McMahon and 

Taylor 1990). Furthermore, data for 1988 show that 

cigarettes are the most heavily advertised product in 

outdoor media (CDC 1990a). A study conducted in 

Columbia, South Carolina, confirmed that African 

American communities have 2.6 times as many billboards advertising cigarettes as white communities 

have (Mayberry and Price 1993). 

In the late 1970s, cigarette producers and their 

advertising agencies were becoming very aware of the 

significance of the African American market, as exemplified by this quotation from a well-known advertising agency: “While Blacks represent only 10.3% of the 

total U.S. population, they account for 18% of all smokers and 31% of all menthol smokers” (Rosser Reeves 

Inc. 1979, p. 12). As a result, tobacco companies have 

heavily advertised and promoted cigarettes to racial/ 

ethnic minorities, particularly African Americans. 

244 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

References 

Advertising Age. "Ebony" survey reveals Negro buying habits. Advertising Age 1950;21(35):16–7. 

Advertising Age. Use of Negro models in ads won’t 

reduce sales to whites, Johnson advises workshop. 

Advertising Age 1968;39(50):24. 

Advertising Age. Black is not only beautiful, it’s profitable. Advertising Age 1969;40(16):94. 

Advertising Age. L&M cigaret[te]s pitched to blacks as 

"super bad." Advertising Age 1971a;42(31):20. 

Advertising Age. Print ads push Eve cigaret[te]s to black 

women. Advertising Age 1971b;42(19):24. 

Advertising Age. Brown & Williamson Tobacco [Co.]. 

Advertising Age 1974;45(34):76–80. 

Ahijevych K, Wewers ME. Factors associated with nicotine dependence among African American women 

cigarette smokers. Research in Nursing and Health 

1993;16(4):283–92. 

Ahluwalia JS, McNagny SE. Smoking prevalence and 

desire to quit in inner-city African American walk-in 

clinic patients. Clinical Research 1993;41(4):752A. 

Ajzen I, Fishbein M. The prediction of behavior from 

attitudinal and normative variables. Journal of Experimental Social Psychology 1970;6(4):466–87. 

Altman DG, Schooler C, Basil MD. Alcohol and 

cigarette advertising on billboards. Health Education 

Research 1991;6(4):487–90. 

Assael S. Why big tobacco woos minorities. Adweek’s 

Marketing Week 1990;XXXI(5):21–30. 

Barban AM, Cundiff EW. Negro and white response 

to advertising stimuli. Journal of Marketing Research 

1964;1(4):536. 

Basil MD, Schooler C, Altman DG, Slater M, Albright 

CL, Maccoby N. How cigarettes are advertised in 

magazines: special messages for special markets. 

Health Communication 1991;3(2):75–91. 

Bauer RA, Greyser SA. Advertising in America: The Consumer View. A Report and Interpretation of the American 

Association of Advertising Agencies’ Study on the Consumer 

Judgment of Advertising. Boston: Harvard University, 

Graduate School of Business Administration, 1968. 

Begay ME, Traynor M, Glantz SA. The tobacco industry, state politics, and tobacco education in California. 

American Journal of Public Health 1993;83(9):1214–21. 

Benson PL, Donahue MJ. Ten-year trends in at-risk 

behaviors: a national study of black adolescents. Journal of Adolescent Research 1989;4(2):125–39. 

Bergin R. Sponsorship and the Arts: A Practical Guide to 

Corporate Sponsorship of the Performing and Visual Arts. 

Evanston (IL): Entertainment Resource Group, 1990. 

Berkman D. Advertising in “Ebony” and “Life”: Negro aspirations vs. reality. Journalism Quarterly 1963; 

40(1):53–64. 

Berry JW. On cross-cultural comparability. International 

Journal of Psychology 1969;4(2):119–28. 

Bettes BA, Dusenbury L, Kerner J, James-Ortiz S, 

Botvin GJ. Ethnicity and psychosocial factors in alcohol and tobacco use in adolescence. Child Development 

1990;61(2):557–65. 

Blum A. Cigarette companies go to college. New York 

State Journal of Medicine 1985;85(7):349. 

Blum A. Selling cigarettes: the blue-collar, black target. The Washington Post 1986 May 18;Sect F:1 (col 2). 

Blum A. The targeting of minority groups by the tobacco industry. In: Jones LA, editor. Minorities and Cancer. New York: Springer-Verlag, 1989:153–62. 

Botvin GJ, Baker E, Botvin EM, Dusenbury L, Cardwell 

J, Diaz T. Factors promoting cigarette smoking among 

black youth: a causal modeling approach. Addictive 

Behaviors 1993;18(4):397–405. 

Botvin GJ, Baker E, Goldberg CJ, Dusenbury L, Botvin 

EM. Correlates and predictors of smoking among black 

adolescents. Addictive Behaviors 1992;17(2):97–103. 

Factors That Influence Tobacco Use 245 
 

Surgeon General’s Report 

Botvin GJ, Epstein JA, Schinke SP, Diaz T. Predictors of 

cigarette smoking among inner-city minority youth. 

Developmental and Behavioral Pediatrics 1994;15(2):67–73. 

Brandweek. UST says "Skoal" to Copa Nacional sponsorship (US Tobacco’s Skoal to sponsor Copa Nacional, 

Hispanic soccer league championship tournament). 

Brandweek 1995;XXXVI(35):14. 

Brislin RW, Lonner WJ, Thorndike RM. Cross-Cultural 

Research Methods. New York: John Wiley & Sons, 1973. 

Brown & Williamson Tobacco Corporation. Kool 

Achiever Awards [Milwaukee presentation program]. 

Louisville (KY): Brown & Williamson Tobacco Corporation, 1993. 

Brownson RC, Jackson-Thompson J, Wilkerson JC, 

Davis JR, Owens NW, Fisher EB Jr. Demographic and 

socioeconomic differences in beliefs about the health 

effects of smoking. American Journal of Public Health 

1992;82(1):99–103. 

Brunswick AF, Messeri P. Causal factors in onset of 

adolescents’ cigarette smoking: a prospective study of 

urban black youth. Advances in Alcohol and Substance 

Abuse 1983;3(1–2):35–52. 

Brunswick AF, Messeri PA. Gender differences in the 

processes leading to cigarette smoking. Journal of Psychosocial Oncology 1984;2(1):49–69. 

Bry BH, McKeon P, Pandina RJ. Extent of drug use as 

a function of number of risk factors. Journal of Abnormal Psychology 1982;91(4):273–9. 

Bullock HA. Consumer motivations in black and white 

II. Harvard Business Review 1961;39(4):110–24. 

Campbell KM, Kaplan CP. Relationship between language orientation and cigarette-smoking beliefs of 

Latinas. American Journal of Health Behavior 1997; 

21(1):12–20. 

Castro FG, Maddahian E, Newcomb MD, Bentler PM. 

A multivariate model of the determinants of cigarette 

smoking among adolescents. Journal of Health and Social Behavior 1987;28(Sept):273–89. 

Castro FG, Sharp EV, Barrington EH, Walton M, 

Rawson RA. Drug abuse and identity in Mexican 

Americans: theoretical and empirical considerations. 

Hispanic Journal of Behavioral Sciences 1991;13(2):209–25. 

Centers for Disease Control. Cigarette advertising— 

United States, 1988. Morbidity and Mortality Weekly 

Report 1990a;39(16):261–5. 

Centers for Disease Control. Cigarette brand use 

among adult smokers—United States, 1986. Morbidity 

and Mortality Weekly Report 1990b;39(38):665, 671–3. 

Centers for Disease Control. Cigarette smoking among 

Chinese, Vietnamese, and Hispanics—California, 

1989–1991. Morbidity and Mortality Weekly Report 

1992;41(20):362–7. 

Centers for Disease Control and Prevention. Changes 

in the cigarette brand preferences of adolescent 

smokers—United States, 1989–1993. Morbidity and 

Mortality Weekly Report 1994a;43(32):577–81. 

Centers for Disease Control and Prevention. Cigarette 

smoking among adults—United States, 1993. Morbidity and Mortality Weekly Report 1994b;43(50):925–30. 

Chaloupka FJ, Laixuthai A. U.S. trade policy and cigarette smoking in Asia. Working paper no. 5543. Cambridge (MA): National Bureau of Economic Research, 

1996. 

Chassin L, Presson CC, Sherman SJ. Social psychological contributions to the understanding and prevention 

of adolescent cigarette smoking. Personality and Social 

Psychology Bulletin 1990;16(1):133–51. 

Chassin L, Presson CC, Sherman SJ, Edwards DA. The 

natural history of cigarette smoking and young adult 

social roles. Journal of Health and Social Behavior 

1992;33(Dec):328–47. 

Chavez EL, Edwards R, Oetting ER. Mexican American and white American school dropouts’ drug use, 

health status, and involvement in violence. Public 

Health Reports 1989;104(6):594–604. 

Chen MS Jr. Cardiovascular health among Asian 

Americans/Pacific Islanders: an examination of health 

status and intervention approaches. American Journal 

of Health Promotion 1993;7(3):199–207. 

Chen MS Jr, Guthrie R, Moeschberger M, Wewers ME, 

Anderson J, Kuun P, et al. Lessons learned and baseline 

data from initiating smoking cessation research with 

Southeast Asian adults. Asian American and Pacific Islander Journal of Health 1993;1(2):194–214. 

246 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Chen TTL, Winder AE. The opium wars revisited as 

U.S. forces tobacco exports in Asia [commentary]. 

American Journal of Public Health 1990;80(6):659–62. 

Congressional Hispanic Caucus Institute, Inc. 1993–1994 

National Directory of Hispanic Organizations. Congressional Hispanic Caucus Institute, Inc. and New York: 

Philip Morris Companies, 1993. 

Conrad KM, Flay BR, Hill D. Why children start smoking cigarettes: predictors of onset. British Journal of 

Addiction 1992;87(12):1711–24. 

Cook TD, Campbell DT. Quasi-Experimentation: Design 

& Analysis Issues for Field Settings. Chicago: Rand 

McNally College Publishing Company, 1979. 

Cooper R, Simmons BE. Cigarette smoking and ill 

health among black Americans. New York State Journal 

of Medicine 1985;85(7):344–9. 

Coreil J, Ray LA, Markides KS. Predictors of smoking 

among Mexican-Americans: findings from the Hispanic HANES. Preventive Medicine 1991;20(4):508–17. 

Cowdery JE, Fitzhugh EC, Wang MQ. Sociobehavioral 

influences on smoking initiation of Hispanic adolescents. Journal of Adolescent Health 1997;20(1):46–50. 

Cummings KM, Giovino G, Mendicino AJ. Cigarette 

advertising and black-white differences in brand preference. Public Health Reports 1987;102(6):698–701. 

Cummings KM, Sciandra R, Lawrence J. Tobacco advertising in retail stores. Public Health Reports 1991;106 

(5):570–5. 

Dagnoli J. RJR’s Uptown targets blacks. Advertising Age 

1989;60(54):4. 

Dallaire VJ. U.S. Negro market growing target for advertisers. Printers’ Ink 1955;252(11):52–62. 

Davis RM. Current trends in cigarette advertising and 

marketing. New England Journal of Medicine 1987; 

316(12):725–32. 

Davis RM. Does the Marlboro Man drink milk? Tobacco 

Control 1993;2(3):246–7. 

De Montaña A. El Tabaco, Monocultivo y Dependencia, 

Colombia Siglo XIX. Bogota DE (Colombia): Universidad Nacional de Colombia, Centro de Investigaciones, 

1978. 

Deshpande R, Hoyer WD, Donthu N. The intensity of 

ethnic affiliation: a study of the sociology of Hispanic 

consumption. Journal of Consumer Research 1986; 

13(2):214–20. 

DiGiacomo F. Doing the right thing. Marketing and 

Media Decisions 1990;25(6):25–32. 

Donthu N, Cherian J. Hispanic coupon usage: the impact of strong and weak ethnic identification. Psychology and Marketing 1992;9(6):501–10. 

Durand RM, Teel JE Jr, Bearden WO. Racial differences 

in perceptions of media advertising credibility. Journalism Quarterly 1979;56(3):562–6. 

Dusenbury L, Epstein JA, Botvin GJ, Diaz T. The relationship between language spoken and smoking 

among Hispanic-Latino youth in New York City. Public Health Reports 1994;109(3):421–7. 

Dusenbury L, Kerner JF, Baker E, Botvin G, James-Ortiz 

S, Zauber A. Predictors of smoking prevalence among 

New York Latino youth. American Journal of Public 

Health 1992;82(1):55–8. 

Elder J, de Moor C, Young RL, Wildey MB, Molgaard 

CA, Golbeck AL, et al. Stages of adolescent tobaccouse acquisition. Addictive Behaviors 1990;15(5):449–54. 

Elder JP, Edwards C, Conway TL. Independent Evaluation of Proposition 99-Funded Efforts to Prevent and 

Control Tobacco Use in California [annual report]. Submitted to California Department of Health Services, 

Tobacco Control Section. San Diego (CA): San Diego 

State University, Graduate School of Public Health, 

1993. 

Elder JP, Molgaard CA, Gresham L. Predictors of chewing tobacco and cigarette use in a multiethnic public 

school population. Adolescence 1988;23(91):689–702. 

Elder JP, Stern RA. The ABCs of adolescent smoking 

prevention: an environment and skills model. Health 

Education Quarterly 1986;13(2):181–91. 

Escobedo LG, Kirch DG, Anda RF. Depression and 

smoking initiation among US Latinos. Addiction 

1996;91(1):113–9. 

Ethridge RF. Tobacco among the Cherokees. Journal of 

Cherokee Studies 1978;3(2):77–86. 

Evans CA Jr. Fighting the pushers in minority America. 

Henry Ford Hospital Medical Journal 1990;38(2–3):164–5. 

Factors That Influence Tobacco Use 247 
 

Surgeon General’s Report 

Evans N, Farkas A, Gilpin E, Berry C, Pierce JP. Influence of tobacco marketing and exposure to smokers 

on adolescent susceptibility to smoking. Journal of the 

National Cancer Institute 1995;87(20):1538–45. 

Ewert D, Alleyne D. Risk of exposure to outdoor advertising of cigarettes and alcohol [letter]. American 

Journal of Public Health 1992;82(6):895–6. 

Farrell AD, Danish SJ, Howard CW. Risk factors for 

drug use in urban adolescents: identification and crossvalidation. American Journal of Community Psychology 

1992;20(3):263–86. 

Federal Register. US Department of Health and Human 

Services, Food and Drug Administration. Regulations 

restricting the sale and distribution of cigarettes and 

smokeless tobacco to protect children and adolescents; 

final rule (21 CFR Parts 801, 803, 804, 807, 820, and 

897), 61 Fed. Reg. 44396 (1996). 

Federal Trade Commission. Report to Congress: Pursuant to the Federal Cigarette Labeling and Advertising Act. 

Washington (DC): Federal Trade Commission, 1997. 

Feigelman W, Gorman B. Toward explaining the higher 

incidence of cigarette smoking among black Americans. Journal of Psychoactive Drugs 1989;21(3):299–305. 

Felix-Ortiz M, Newcomb MD. Risk and protective factors for drug use among Latino and white adolescents. 

Hispanic Journal of Behavioral Sciences 1992;14(3): 

291–309. 

Felix-Ortiz M, Newcomb MD. Cultural identity and 

drug use among Latino and Latina adolescents. In: 

Botvin GJ, Schinke SP, Orlandi MA, editors. Drug Abuse 

Prevention With Multiethnic Youth. Thousand Oaks 

(CA): Sage Publications, 1995:147–65. 

Fernandez E. Butt out, tobacco sponsors told Tet festival officials won’t accept ads for smoking, gambling. 

San Francisco Examiner 1996 Feb 18;Sect B:8. 

Fisher I. Tobacco funds go to black officials. New York 

Times 1995 Nov 19;Sect 1:21 (col 1). 

Foner PS. Organized Labor and the Black Worker 1619– 

1981. New York: International Publishers, 1981. 

Food and Agriculture Organization of the United Nations. FAO Yearbook/Annuaire/Anuario: Production/Production/Producción, Vol. 49, 1995. FAO Statistics Series 

No. 130. Rome: Food and Agriculture Organization of 

the United Nations, 1996. 

Fortuine R. Chills and Fever: Health and Disease in the 

Early History of Alaska. Fairbanks (AK): University of 

Alaska Press, 1989. 

Frankel G, Mufson S. Vast China market key to smoking disputes. The Washington Post 1996 Nov 20;Sect A:1. 

Gale F. Tobacco economies: what’s ahead? Agricultural 

Outlook 1993;Sept:27–31. 

Gitter AG, O’Connell SM, Mostofsky D. Trends in appearance of models in Ebony ads over 17 years. Journalism Quarterly 1972;49(3):547–50. 

Gloede WF. RJR puts on the Ritz; PM goes to Rio. Advertising Age 1985;56(2):1, 78. 

Goldberger P. Philip Morris calls in I.O.U.’s in the arts. 

The New York Times 1994 Oct 5;Sect A:1 (col 2). 

Goodman J. Tobacco in History: The Cultures of Dependence. London: Routledge, 1992. 

Green MK. Images of Native Americans in advertising: some moral issues. Journal of Business Ethics 1993; 

12(4):323–30. 

Gross AE. Skoal rides tobacco road. Promote 1989 

Sept:11. 

Guthrie P. Some contend that American Spirits 

violate Indian spirit. Albuquerque Tribune 1997 July 

12:Sect A:9. 

Haberman TW. Evidence for aboriginal tobaccos in 

eastern North America. American Antiquity 1984; 

49(2):269–87. 

Hahn LP, Folsom AR, Sprafka JM, Norsted SW. Cigarette smoking and cessation behaviors among urban 

blacks and whites. Public Health Reports 1990;105 

(3):290–5. 

Haile SW, editor. National Directory of Corporate Giving. 2nd ed. New York: The Foundation Center, 1991. 

Hall RL, Dexter D. Smokeless tobacco use and attitudes 

toward smokeless tobacco among Native Americans 

and other adolescents in the Northwest. American Journal of Public Health 1988;78(12):1586–8. 

248 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Hawkins JD, Catalano RF, Miller JY. Risk and protective factors for alcohol and other drug problems in 

adolescence and early adulthood: implications for substance abuse prevention. Psychological Bulletin 

1992;112(1):64–105. 

Headen SW, Bauman KE, Deane GD, Koch GG. Are 

the correlates of cigarette smoking initiation different 

for black and white adolescents? American Journal of 

Public Health 1991;81(7):854–8. 

Hodge FS. Tobacco control leadership in American 

Indian communities. In: Slama K, editor. Tobacco and 

Health. New York: Plenum Press, 1995:375–8. 

Hodge FS, Cummings SR, Frederick L, Kipnis P. Prevalence of Smoking/Smokeless Tobacco Use in 18 Northern 

California American Indian Health Clinics. Vol. A. Berkeley (CA): Center for American Indian Research and 

Education, American Indian Cancer Control Project, 

May 1994. 

Hodge FS, Fredericks L, Kipnis P. Patient and smoking patterns in Northern California American Indian 

clinics: urban and rural contrasts. Cancer (Suppl) 

1996;78(7):1623–8. 

Hodge FW. Handbook of American Indians North of 

Mexico. Bulletin No. 30. Washington (DC): Smithsonian 

Institution, Bureau of American Ethnology, 1910. 

Hoffman A, Cooper R, Lacey L, Mullner R. Cigarette 

smoking and attitudes toward quitting among black 

patients. Journal of the National Medical Association 

1989;81(4):415–20. 

Hoffman-Goetz L, Gerlach KK, Marino C, Mills SL. 

Cancer coverage and tobacco advertising in AfricanAmerican women’s popular magazines. Journal of Community Health 1997;22(4):261–70. 

Huang PP, Burton D, Howe HL, Sosin DM. Black-white 

differences in appeal of cigarette advertisements 

among adolescents. Tobacco Control 1992;1(4):249–55. 

Jackson DZ. Cash from the hand that kills them. Boston Globe 1992 Sept 23;Sect OP-ED:17 (col 1). 

Jackson DZ. Making money by any means necessary. 

Boston Globe 1995 Feb 1;Sect OP-ED:13. 

Jenkins CNH, McPhee SJ, Bird JA, Bonilla N-TH. Cancer risks and prevention practices among Vietnamese 

refugees. Western Journal of Medicine 1990;153(1):34–9. 

Jepson C, Kessler LG, Portnoy B, Gibbs T. Black-white 

differences in cancer prevention knowledge and behavior. American Journal of Public Health 1991;81(4): 

501–4. 

Jessor R, Jessor SL. Problem Behavior and Psychosocial 

Development: A Longitudinal Study of Youth. New York: 

Academic Press, 1977. 

Jet. Ray Charles, B. B. King join Superband’s annual 

world tour to promote jazz music. Jet 1990;78(16):36. 

Johnson D. Jordan’s role. The Nation 1992a;255(21):761. 

Johnson DR. Tobacco stains: cigarette firms buy into 

African-American groups. The Progressive 1992b;56 

(12):26–8. 

Jones BW. Race, sex, and class: black female tobacco 

workers in Durham, North Carolina, 1920–1940, and 

the development of female consciousness. Feminist 

Studies 1984;10(3):441–51. 

Joyner T. Reynolds presents jewel of a gift to college 

fund. The Charlotte Observer 1984 Nov 12;Sect B:15 

(col 1). 

Kandel DB. Drug and drinking behavior among youth. 

Annual Review in Sociology 1980;6:235–85. 

Kaufman P, Frase MJ. Dropout Rates in the United States: 

1989. Washington (DC): US Department of Education, 

Office of Educational Research and Improvement, 

National Center for Education Statistics, Information 

Services. NCES Publication No. 90-659, 1990. 

Kaufman SB. Challenge & Change: The History of the Tobacco Workers International Union. Kensington (MD): 

Baker, Confectionery and Tobacco Workers International Union, 1986. 

Kizer KW, Honig B, Allenby CL, Deukmejian G. Toward a Tobacco-Free California: A Status Report to the California Legislature on the First Fifteen Months of California’s 

Tobacco Control Program. Sacramento (CA): California 

Department of Health Services and California Department of Education, 1990. 

Klesges RC, Somes G, Pascale RW, Klesges LM, 

Murphy M, Brown K, et al. Knowledge and beliefs regarding the consequences of cigarette smoking and 

their relationships to smoking status in a biracial 

sample. Health Psychology 1988;7(5):387–401. 

Factors That Influence Tobacco Use 249 
 

Surgeon General’s Report 

Koepke D, Flay BR, Johnson CA. Health behaviors in 

minority families: the case of cigarette smoking. Family Community Health 1990;13(1):35–43. 

Koeppel D. In Philadelphia, R.J. Reynolds made all the 

wrong moves. Adweek’s Marketing Week 1990a;31(5): 

20–2. 

Koeppel D. Japan’s Mild 7 cigarette targets Asians in 

the U.S. Adweek’s Marketing Week 1990b;31(33):4–5. 

Korstad R, Lichtenstein N. Opportunities found and 

lost: labor, radicals, and the early civil rights movement. Journal of American History 1988;75(1): 

786–811. 

Kulikoff A. Tobacco and Slaves: The Development of Southern Cultures in the Chesapeake, 1680–1800. Chapel Hill 

(NC): University of North Carolina Press, 1986. 

Lacey LP, Manfredi C, Balch G, Warnecke RB, Allen K, 

Edwards C. Social support in smoking cessation 

among black women in Chicago public housing. Public Health Reports 1993;108(3):387–94. 

Lando HA, Johnson KM, Graham-Tomasi RP, 

McGovern PG, Solberg L. Urban Indians’ smoking 

patterns and interest in quitting. Public Health Reports 

1992;107(3):340–4. 

Landrine H, Richardson JL, Klonoff EA, Flay B. Cultural diversity in the predictors of adolescent cigarette 

smoking: the relative influence of peers. Journal of Behavioral Medicine 1994;17(3):331–46. 

Larino MD, Nevid JS, Javier R. Smoking patterns in 

Hispanic Americans in relation to region of origin. 

Paper presented at the meeting of the American Psychological Association, Toronto, August 1993. 

Laufer B. Tobacco and its Use in Asia [leaflet]. Chicago: 

Field Museum of Natural History, 1924. 

Lee DJ, Markides KS. Health behaviors, risk factors, 

and health indicators associated with cigarette use in 

Mexican Americans: results from the Hispanic 

HANES. American Journal of Public Health 1991;81 

(7):859–64. 

Lee S, Barnes JH Jr. Using color preferences in magazine advertising. Journal of Advertising Research 1989– 

1990;29(6):25–30. 

Lerner G, editor. Black Women in White America: A Documentary History. New York: Vintage Books, 1973. 

Levin M, Perry T. Museum ditches Philip Morris as 

sponsor. Los Angeles Times 1996 May 1;Sect D:2. 

Leviten P. Manufacturers send changing smoke signals. Supermarket Business 1985;40(12):39–43. 

Lew R. Tobacco control in the Asian Pacific Islander 

community: from research to implementation. Paper 

presented at the 8th World Conference on Tobacco or 

Health, Buenos Aires, March 30–April 3, 1992. 

Linton R. Use of Tobacco Among North American Indians 

[leaflet]. Chicago: Field Museum of Natural History, 

1924. 

Lovato CY, Litrownik AJ, Elder J, Nuñez-Liriano A, 

Suarez D, Talavera GA. Cigarette and alcohol use 

among migrant Hispanic adolescents. Family and Community Health 1994;16(4):23–36. 

Lynch BS, Bonnie RJ, editors. Growing Up Tobacco Free: 

Preventing Nicotine Addiction in Children and Youths. 

Washington (DC): National Academy Press, 1994. 

Mackay J, Bounxouie B. Laos—“the land of smiles” 

(and smokes). Tobacco Control 1994;3(1):10–1. 

Mackay J, Shiru N, Charlton A, Lam TH, Moyer C. 

Smoking among Chinese youth: a cure for crying? 

Tobacco Control 1993;2(1):7–8. 

Maddahian E, Newcomb MD, Bentler PM. Adolescents’ substance use: impact of ethnicity, income, and 

availability. Advances in Alcohol and Substance Abuse 

1986;5(3):63–78. 

Maddahian E, Newcomb MD, Bentler PM. Adolescent 

drug use and intention to use drugs: concurrent and 

longitudinal analyses of four ethnic groups [brief report]. Addictive Behaviors 1988;13(2):191–5. 

Mahony D, Nevid JS, Javier RA. Acculturation and 

smoking patterns among Hispanic smokers seeking to 

quit. Paper presented at the meeting of the American 

Psychological Association, Toronto, August 1993. 

Marín BV, Marín G, Pérez-Stable EJ, Otero-Sabogal R, 

Sabogal F. Cultural differences in attitudes toward 

smoking: developing messages using the theory of 

reasoned action. Journal of Applied Social Psychology 

1990b;20(6):478–93. 

250 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Marín G. Issues in the measurement of acculturation 

among Hispanics. In: Geisinger KF, editor. Psychological Testing of Hispanics. Washington (DC): American 

Psychological Association, 1992:1235–51. 

Marín G, Marín BV. Research with Hispanic Populations. 

Applied Social Research Methods Series, Vol. 23. 

Newbury Park (CA): Sage Publications, 1991. 

Marín G, Marín BV, Otero-Sabogal R, Sabogal F, PérezStable EJ. The role of acculturation in the attitudes, 

norms, and expectancies of Hispanic smokers. Journal 

of Cross-Cultural Psychology 1989a;20(4):399–415. 

Marín G, Marín BV, Pérez-Stable EJ, Sabogal F, OteroSabogal R. Cultural differences in attitudes and expectancies between Hispanic and non-Hispanic white 

smokers. Hispanic Journal of Behavioral Sciences 

1990a;12(4):422–36. 

Marín G, Pérez-Stable EJ, Otero-Sabogal R, Sabogal F, 

Marín BV. Stereotypes of smokers held by Hispanic 

and white non-Hispanic smokers. International Journal 

of the Addictions 1989b;24(3):203–13. 

Marriott M. Teacher program is given a boost. The New 

York Times 1992 Jan 12;Sect L:13 (col 1). 

Maxwell B, Jacobson M. Marketing Disease to Hispanics: The Selling of Alcohol, Tobacco, and Junk Foods. Washington: Center for Science in the Public Interest, 1989. 

Mayberry RM, Price PA. Targeting blacks in cigarette 

billboard advertising: results from down South. Health 

Values 1993;17(1):28–35. 

McCullen JT Jr. Indian myths concerning the origin of 

tobacco. New York Folklore Quarterly 1967;23(4):264–73. 

McIntosh H. Black teens not smoking in great numbers. Journal of the National Cancer Institute 1995; 

87(8):564. 

McMahon ET, Taylor PA. Citizens’ Action Handbook on 

Alcohol and Tobacco Billboard Advertising. Washington 

(DC): Center for Science in the Public Interest and 

Scenic America, 1990. 

Mermelstein R, Robinson R, Ericksen M, Crosset L, 

Feldman S. Explanations of race and gender differences 

in teen tobacco use. Paper presented at the 124th 

annual meeting of the American Public Health Association, New York City, November 19, 1996. 

Meyer JA. Cigarette century. American Heritage 1992; 

43(8):72–80. 

Milligan S. Eyes on the lies: how black leaders and cigarette companies have turned indoor smoking into a 

civil rights issue. The Washington Monthly 1987; 

19(5):39–42. 

Milloy C. Ethics go up in smoke. The Washington Post 

1990 Apr 1;Sect D:3 (col 4). 

Mitchell D. Images of exotic women in turn-of-thecentury tobacco art. Feminist Studies 1992;18(2):327–50. 

Mitchell O, Greenberg M. Outdoor advertising of addictive products. New Jersey Medicine 1991;88(5):331–3. 

Moeschberger ML, Anderson J, Kuo YF, Chen MS, 

Wewers ME, Guthrie R. Multivariate profile of smoking in Southeast Asian men: a biochemically verified 

analysis. Preventive Medicine 1997;26(1):53–8. 

Moncher MS, Holden GW, Trimble JE. Substance abuse 

among Native-American youth. Journal of Consulting 

and Clinical Psychology 1990;58(4):408–15. 

Moore DJ, Williams JD, Qualls WJ. Target marketing 

of tobacco and alcohol-related products to ethnic minority groups in the United States. Ethnicity & Disease 

1996;6(1,2):83–98. 

Murphy PE. Analyzing markets. In: Frederiksen LW, 

Solomon LJ, Brehony KA, editors. Marketing Health 

Behavior: Principles, Techniques, and Applications. New 

York: Plenum Press, 1984:41–58. 

Nabisco Foods Group. Models of success [advertisement]. Ebony 1992;47(8):2. 

Nardi J-B. A Historia do Fumo Brasileiro. Rio de Janeiro: 

ABIFUMO, 1985. 

National Association of Convenience Stores. State of 

the Industry: Convenience Store Industry Totals, Trends & 

Averages. Alexandria (VA): National Association of 

Convenience Stores, 1993. 

National Black Monitor. The black press and the tobacco industry. National Black Monitor 1990;15(7):4. 

Nelson JR Jr, Lucas JE. Target: minorities. Marketing 

and Media Decisions 1990;25(10):70–1. 

Factors That Influence Tobacco Use 251 
 

Surgeon General’s Report 

Newcomb MD, Bentler PM. Consequences of Adolescent 

Drug Use: Impact on the Lives of Young Adults. Newbury 

Park (CA): Sage Publications, 1988. 

Newcomb MD, Felix-Ortiz M. Multiple protective and 

risk factors for drug use and abuse: cross-sectional and 

prospective findings. Journal of Personality and Social 

Psychology 1992;63(2):280–96. 

Newcomb MD, Maddahian E, Bentler PM. Risk factors for drug use among adolescents: concurrent and 

longitudinal analyses. American Journal of Public Health 

1986;76(5):525–31. 

Newcomb MD, Maddahian E, Skager R, Bentler PM. 

Substance abuse and psychosocial risk factors among 

teenagers: associations with sex, age, ethnicity, and 

type of school. American Journal of Drug and Alcohol 

Abuse 1987;13(4):413–33. 

Northrup HR, Ash RI. The Racial Policies of American 

Industry: The Negro in the Tobacco Industry. Report No. 

13. Philadelphia (PA): University of Pennsylvania, 

Wharton School of Finance and Commerce, Department of Industry, Industrial Research Unit, 1970. 

O’Campo P, Faden RR, Brown H, Gielen AC. The impact of pregnancy on women’s prenatal and postpartum smoking behavior. American Journal of Preventive 

Medicine 1992;8(1):8–13. 

O’Connor JJ. Salem Extra menthol to challenge Kool 

leadership. Advertising Age 1974;45(39):2, 94. 

Organization of Chinese Americans. National Directory of Asian Pacific Americans 1997–1998. New York: 

Philip Morris Companies Inc., 1997. 

Orleans CT, Schoenbach VJ, Salmon MA, Strecher VJ, 

Kalsbeek W, Quade D, et al. A survey of smoking and 

quitting patterns among black Americans. American 

Journal of Public Health 1989;79(2):176–81. 

Paper J. Offering Smoke: The Sacred Pipe and Native 

American Religion. Moscow (ID): University of Idaho 

Press, 1988. 

Pérez-Stable EJ, Marín G, Marín BV, Katz MH. Depressive symptoms and cigarette smoking among Latinos 

in San Francisco. American Journal of Public Health 

1990;80(12):1500–2. 

Philadelphia News Observer. R.J. Reynolds to test 

market new product in Philadelphia. The Philadelphia 

News Observer 1990 Jan 3;7 (col 1). 

Philip Morris Companies Inc. Guide to Black Organizations, 1992–94 Edition. New York: Philip Morris Companies, 1992. 

Pickering J, Lavallee C, Hanley J. Cigarette smoking 

in Cree Indian school children of the James Bay region. 

Arctic Medical Research 1989;48(1):6–11. 

Pierce JP, Choi WS, Gilpin EA, Farkas AJ. Validation 

of suceptibility as a predictor of which adolescents take 

up smoking in the United States. Health Psychology 

1996;15(5):355–61. 

Pitts RE, Whalen DJ, O’Keefe R, Murray V. Black and 

white response to culturally targeted television commercials: a values-based approach. Psychology and 

Marketing 1989;6(4):311–28. 

Pollay RW. Promotion and policy for a pandemic product: notes on the history of cigarette advertising [working papers and research reprints]. Vancouver (Canada): 

The History of Advertising Archives, University of 

British Columbia, 1988. 

Pollay RW. Black and white and read all over: cigarette advertising in Ebony and Life [1950–1965] [working papers and research reprints]. Vancouver (Canada): 

The History of Advertising Archives, University of 

British Columbia, 1990. 

Pollay RW, Lee JS, Carter-Whitney D. Separate, but not 

equal: racial segmentation in cigarette advertising. 

Journal of Advertising 1992;21(1):45–57. 

Printers’ Ink. What’s news . . . and why: Philip Morris 

plans cyclic ad program. Printers’ Ink 1955;250(13):20. 

Printers’ Ink. Menthol cigarette competition tightens 

as more major entries crowd into race. Printers’ Ink 

1959a;267(11):11–2. 

Printers’ Ink. Porous appeals [editorial]. Printers’ Ink 

1959b;268(4):8. 

Printers’ Ink. ROP color: do ad men know its power? 

Printers’ Ink 1959c;268(13):37–44. 

Prochaska JO, DiClemente CC. Stages and processes 

of self-change of smoking: toward an integrative model 

of change. Journal of Consulting and Clinical Psychology 

1983;51(3):390–5. 

Ramirez A. A cigarette campaign under fire. The New 

York Times 1990 Jan 12;Sect D:1 (col 3). 

252 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Riley WT, Barenie JT, Mabe PA, Myers DR. The role of 

race and ethnic status on the psychosocial correlates 

of smokeless tobacco use in adolescent males. Journal 

of Adolescent Health 1991;12(1):15–21. 

Rivero Muñiz J. Tabaco, su Historia en Cuba. La Habana 

(Cuba): Instituto de Historia, Comision Nacional de la 

Academia de Ciencias de la Republica de Cuba, 1964. 

RJR Nabisco, Inc. A Growing Presence in the Mainstream. 

Winston-Salem (NC): RJR Nabisco, Programs for Minorities and Women, 1986. 

Robinson RG. The tobacco industry and the African 

American community: from compromise to empowerment. Paper presented at the 8th World Conference 

on Tobacco or Health, Buenos Aires, March 30–April 

3, 1992. 

Robinson RG, Barry M, Bloch M, Glantz S, Jordan J, 

Murray KB, et al. Report of the tobacco policy research 

group on marketing and promotions targeted at 

African Americans, Latinos, and women. Tobacco Control 1992a;1(Suppl):S24–S30. 

Robinson RG, Pertschuk M, Sutton C. Smoking and 

African Americans: spotlighting the effects of smoking and tobacco promotion in the African American 

community. In: Samuels SE, Smith MD, editors. Improving the Health of the Poor: Strategies for Prevention. 

Menlo Park (CA): The Henry J. Kaiser Family Foundation, 1992b:123–81. 

Robinson RG, Shelton DM, Hodge F, Lew R, Lopes E, 

Toy P, et al. Tobacco control capacity index for communities of color in the United States. In: Slama K, 

editor. Tobacco and Health. New York: Plenum Press, 

1995:359–65. 

Robinson RG, Sutton CD. The Coalition Against Uptown Cigarettes. In: Jernigan D, Wright P, editors. 

Making News, Changing Policy. Washington (DC): US 

Office of Personnel Management, Center for Substance 

Abuse Prevention, and The Marin Institute for the Prevention of Alcohol and Other Drug Problems, in press. 

Romano PS, Bloom J, Syme SL. Smoking, social support, and hassles in an urban African-American 

community. American Journal of Public Health 1991; 

81(11):1415–22. 

Roper Center for Public Opinion Research. Attitudes 

on Smoking by Race. Telephone Survey Conducted from 

February 25 to 28, 1993. Storrs (CT): Roper Center for 

Public Opinion Research, University of Connecticut, 

conducted by ABC News/The Washington Post, 1993. 

Ros Torres MA. La Producción Cigarrera a Finales de la 

Colonia: La Fabrica en México. Mexico (DF): Instituto 

Nacional de Antropología e Historia, 1984. 

Rosenberg ND. Costly talk: activist refuses $5,000 

award. The Milwaukee Journal 1993 Sept 30;Sect A:1. 

Rosenblatt R. How do tobacco executives live with 

themselves? The New York Times Magazine 1994 Mar 

20:34. 

Rosser Reeves Inc. Arctic Lights: Strategic Brand Conference, Brand Issues/Strategies/Tactics: May 17, 1979, 

minutes. Madison (WI): M86-426, Box 2, Papers of 

Rosser Reeves, State Historical Society of Wisconsin, 

1979. 

Rothstein M. Uneasy partners: arts and Philip Morris. 

The New York Times 1990 Dec 18;Sect C:15 (col 2). 

Rotzoll BW. New cigarettes target black kids, foes say. 

Chicago Sun-Times 1997 Feb 2;Sunday News Sect:23. 

Royce JM, Hymowitz N, Corbett K, Hartwell TD, 

Orlandi MA. Smoking cessation factors among African Americans and whites. American Journal of Public 

Health 1993;83(2):220–6. 

Russ VM. Is it philanthropy or a smoke screen? cigarette makers give to black causes. Philadelphia Daily 

News 1993 Aug 2;Lifestyle Sect:38, 40. 

Sabogal F, Otero-Sabogal R, Pérez-Stable EJ, Marín BV, 

Marín G. Perceived self-efficacy to avoid cigarette 

smoking and addiction: differences between Hispanics and non-Hispanic whites. Hispanic Journal of Behavioral Sciences 1989;11(2):136–47. 

Samet JM, Howard CA, Coultas DB, Skipper BJ. Acculturation, education, and income as determinants of 

cigarette smoking in New Mexico Hispanics. Cancer 

Epidemiology, Biomarkers & Prevention 1992;1(3):235–40. 

San Diego Union-Tribune. Fair board sends Marlboro 

packing: Marlboro cigarettes promotional contract 

with Del Mar Fair Board to end. San Diego UnionTribune 1996 Apr 2:Sect A:1. 

Factors That Influence Tobacco Use 253 
 

Surgeon General’s Report 

Sanchez L. Anti-smoking efforts take aim at Latinos. 

The San Diego Union-Tribune 1993 June 25;Sect B:3 

(col 1). 

Satcher D, Robinson RG. The CDC and the NMA— 

partnerships to control tobacco in the AfricanAmerican community. Journal of the National Medical 

Association 1994;86(7):493–6. 

Scheier LM, Newcomb MD. Differentiation of early 

adolescent predictors of drug use versus abuse: a 

developmental risk-factor model. Journal of Substance 

Abuse 1991;3(3):277–99. 

Schinke SP, Moncher MS, Holden GW, Botvin GJ, 

Orlandi MA. American Indian youth and substance 

abuse: tobacco use problems, risk factors and preventive interventions. Health Education Research 1989; 

4(1):137–44. 

Schinke SP, Orlandi MA, Schilling RF, Botvin GJ, 

Gilchrist LD, Landers C. Tobacco use by American Indian and Alaska Native people: risks, psychosocial 

factors, and preventive intervention. Journal of Alcohol 

and Drug Education 1990;35(2):1–12. 

Schinke S, Orlandi M, Vaccaro D, Espinoza R, 

McAlister A, Botvin G. Substance use among Hispanic 

and non-Hispanic adolescents. Addictive Behaviors 

1992;17(2):117–24. 

Schmeltzer J. “Mainstream” spending up by minorities; study shows buying of cars and computers surging among African-Americans as upbeat view of 

economy spreads. Chicago Tribune 1996 Aug 28;Business Sect:1. 

Seig L. Tobacco, Peace Pipes, and Indians. Palmer Lake 

(CO): The Filter Press, 1971. 

Sesser S. Opium war redux. The New Yorker 1993; 

69(29):78–89. 

Shelton DM, Merritt RK, Robinson RG. Tobacco control strategies. In: Slama K, editor. Tobacco and Health. 

New York: Plenum Press, 1995:367–74. 

Sherman G. Tobacco pipes of the Western Eskimos. 

Beaver 1972;303(1):49–51. 

Siegel RK. Intoxication: Life in Pursuit of Artificial Paradise. New York: E. P. Dutton, 1989. 

Simmons S. New cig is aimed at black smokers: Uptown to be tested here. Philadelphia Daily News 1989 

Dec 14;Business Sect:51. 

Smith KW, McGraw SA, Carrillo JE. Factors affecting 

cigarette smoking and intention to smoke among 

Puerto Rican-American high school students. Hispanic 

Journal of Behavioral Sciences 1991;13(4):401–11. 

Smith L. Big apple breathes easy. Tobacco Control 

1995;4(1):15–7. 

Solberg EJ, Blum A. Tobacco money buys minorities’ 

political support. Tobacco Control 1992;1(4):245–6. 

Soley LC, Reid LN. Satisfaction with the informational 

value of magazine and television advertising. Journal 

of Advertising 1983;12(3):27–31. 

Spangler JG, Dignan MB, Michielutte R. Correlates of 

tobacco use among Native American women in western North Carolina. American Journal of Public Health 

1997;87(1):108–11. 

Stanley BN. New deal: an increasing number of 

minority-owned businesses land contracts with Philip 

Morris. Richmond Times-Dispatch 1996 Feb 12;Sect D:14. 

Stebbins KR. Transnational tobacco companies and 

health in underdeveloped countries: recommendations 

for avoiding a smoking epidemic. Social Science and 

Medicine 1990;30(2):227–35. 

Stern RA, Prochaska JO, Velicer WF, Elder JP. Stages of 

adolescent cigarette smoking acquisition: measurement and sample profiles. Addictive Behaviors 1987; 

12(4):319–29. 

Stoddard JL, Johnson CA, Boley-Cruz T, Sussman S. 

Targeted tobacco markets: outdoor advertising in Los 

Angeles minority neighborhoods [letter]. American 

Journal of Public Health 1997;87(7):1232–3. 

Sussman S, Dent CW, Flay BR, Hansen WB, Johnson 

CA. Psychosocial predictors of cigarette smoking onset by white, black, Hispanic, and Asian adolescents 

in Southern California. Morbidity and Mortality Weekly 

Report 1987;36(4 Suppl):11S–16S. 

Tamir A, Cachola S. Hypertension and other cardiovascular risk factors. In: Zane NWS, Takeuchi DT, 

Young KNJ, editors. Confronting Critical Health Issues 

of Asian and Pacific Islander Americans. Thousand Oaks 

(CA): Sage Publications, 1994:209–46. 

254 Chapter 4 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Tide. Philip Morris. Tide 1948;22(33):18. 

Tobacco Merchants Association of the United States. 

The TMA Directory of Cigarette Brand Names 1913–1977. 

New York: Tobacco Merchants Association of the 

United States, 1978. 

Tomás Rivera Center. Resolving a Crisis in Education: 

Latino Teachers for Tomorrow’s Classrooms. Claremont 

(CA): Tomás Rivera Center, 1993. 

Triandis HC, Marín G. Etic plus emic versus pseudoetic: a test of a basic assumption of contemporary 

cross-cultural psychology. Journal of Cross-Cultural 

Psychology 1983;14(4):489–500. 

Tuckson RV. Race, sex, economics, and tobacco advertising [editorial]. Journal of the National Medical Association 1989;81(11):1119–24. 

Ullman Gravure, Inc. TransPlastix dynamic plastic displays [advertisement]. Printers’ Ink 1957;258(13):82. 

US Bureau of the Census. 1990 Census of Population: 

Asians and Pacific Islanders in the United States. 

Washington (DC): US Department of Commerce, Economics and Statistics Administration, Bureau of the 

Census. Publication No. CP-3-5, 1993. 

US Commission on Civil Rights. The Decline of Black 

Farming in America: A Report of the United States Commission on Civil Rights. Washington (DC): US Commission on Civil Rights, 1982. 

US Congress. Advertising of Tobacco Products. Hearings before the Subcommittee on Health and the Environment of the Committee on Energy and Commerce, 

House of Representatives, 99th Congress, 2nd Sess. 

Washington (DC): US Government Printing Office. 

Serial No. 99-167, 1987. 

US Congress. Tobacco Issues (Part 2). Hearings before 

the Subcommittee on Transportation and Hazardous 

Materials of the Committee on Energy and Commerce, 

House of Representatives, 101st Congress. Washington (DC): US Government Printing Office. Serial No. 

101-126, 1990. 

US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of 

Progress. A Report of the Surgeon General. Atlanta: US 

Department of Health and Human Services, Public 

Health Service, Centers for Disease Control, Center for 

Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health. DHHS Publication No. 

(CDC) 89-8411, 1989. 

US Department of Health and Human Services. Tobacco 

Use in 1986: Methods and Basic Tabulations from Adult 

Use of Tobacco Survey. Rockville (MD): US Department 

of Health and Human Services, Public Health Service, 

Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health. DHHS Publication No. (OM) 90­

2004, 1990. 

US Department of Health and Human Services. Smoking and Health in the Americas. A 1992 Report of the Surgeon General. Atlanta: US Department of Health and 

Human Services, Centers for Disease Control, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 92-8419, 1992. 

US Department of Health and Human Services. Preventing Tobacco Use Among Young People. A Report of the 

Surgeon General. Atlanta: US Department of Health and 

Human Services, Public Health Service, Centers for 

Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health, 1994. 

US Newswire, Inc. Business Policy Review Council to 

honor black corporate pioneers. Washington (DC): US 

Newswire, Inc., February 1, 1997. 

Vander Martin R, Cummings SR, Coates TJ. Ethnicity 

and smoking: differences in white, black, Hispanic, and 

Asian medical patients who smoke. American Journal 

of Preventive Medicine 1990;6(4):194–9. 

Vanderschmidt HF, Lang JM, Knight-Williams V, 

Vanderschmidt GF. Risks among inner-city young 

teens: the prevalence of sexual activity, violence, drugs, 

and smoking. Journal of Adolescent Health 1993;14(4): 

282–8. 

Vega WA, Zimmerman RS, Warheit GJ, Apospori E, 

Gil AG. Risk factors for early adolescent drug use in 

four ethnic and racial groups. American Journal of Public Health 1993;83(2):185–9. 

Factors That Influence Tobacco Use 255 
 

Surgeon General’s Report 

Villarosa L. Body and soul. Women’s Review of Books 

1994;11(10–11):13–4. 

Wall KA. Positioning your brand in the black market. 

Advertising Age 1973;44(25):71–6. 

Wallace JM Jr, Bachman JG. Explaining racial/ethnic 

differences in adolescent drug use: the impact of background and lifestyle. Social Problems 1991;38(3):333–57. 

Wallace JM Jr, Bachman JG. Validity of self-reports in 

student-based studies on minority populations: issues 

and concerns. In: De La Rosa MR, Adrados J-LR, editors. Drug Abuse Among Minority Youth: Advances in 

Research and Methodology. National Institute on Drug 

Abuse Research Monograph No. 130. Rockville (MD): 

US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Drug Abuse, 1993:167–200, NIH 

Publication No. 93-3479. 

Walters DKH. Cigarettes; makers aim at special niches 

to boost sales. Los Angeles Times 1985 Sept 15;Business 

Sect:1(col 3). 

Warnecke RB, Graham S, Rosenthal S, Manfredi C. 

Social and psychological correlates of smoking behavior among black women. Journal of Health and Social 

Behavior 1978;19(4):397–410. 

Warner KE. Cigarette advertising and media coverage 

of smoking and health. New England Journal of Medicine 1985;312(6):384–8. 

Warner KE. Selling Smoke: Cigarette Advertising and 

Public Health. Washington (DC): American Public 

Health Association, 1986. 

Warner KE, Goldenhar LM, McLaughlin CG. Cigarette 

advertising and magazine coverage of the hazards of 

smoking—a statistical analysis. New England Journal 

of Medicine 1992;326(5):305–9. 

Watts WD, Wright LS. The relationship of alcohol, tobacco, marijuana, and other illegal drug use to delinquency among Mexican-American, black, and white 

adolescent males. Adolescence 1990;25(97):171–81. 

Webster C. Attitudes toward marketing practices: the 

effects of ethnic identification. Journal of Applied 

Business Research 1990–1991;7(2):107–16. 

Webster C. The effects of Hispanic subcultural identification on information search behavior. Journal of Advertising Research 1992;32(5):54–62. 

Weibel-Orlando J. Indians, ethnicity, and alcohol: contrasting perceptions of the ethnic self and alcohol use. 

In: Bennett LA, Ames GM, editors. The American Experience With Alcohol: Contrasting Cultural Perspectives. 

New York: Plenum Press, 1985:201–26. 

Weinrich S, Hardin S, Valois RF, Gleaton J, Weinrich 

M, Garrison CZ. Psychological correlates of adolescent 

smoking in response to stress. American Journal of Health 

Behavior 1996;20(1):52–60. 

Weiss W. Mass media and social change. In: King BT, 

McGinnies E, editors. Attitudes, Conflict, and Social 

Change. New York: Academic Press, 1972:137–54. 

Weng L-J, Newcomb MD, Bentler PM. Factors influencing noncompletion of high school: a comparison 

of methodologies. Educational Research Quarterly 1988; 

12(2):8–22. 

Whittler TE. Viewers’ processing of actor’s race and 

message claims in advertising stimuli. Psychology and 

Marketing 1989;6(4):287–309. 

Wiecha JM. Differences in patterns of tobacco use in 

Vietnamese, African-American, Hispanic, and Caucasian adolescents in Worcester, Massachusetts. American Journal of Preventive Medicine 1996;12(1):29–37. 

Wildey MB, Young RL, Elder JP, de Moor C, Wolf KR, 

Fiske KE, et al. Cigarette point-of-sale advertising in 

ethnic neighborhoods in San Diego, California. Health 

Values 1992;16(1):23–8. 

Williams L. Tobacco companies target blacks with ads, 

donations and festivals. Wall Street Journal 1986 Oct 

6;33(col 4). 

Wootten HM. Filters push cigarette sales up 4.9%. 

Printers’ Ink 1957;261(13):22–7. 

Yamaguchi K, Kandel DB. On the resolution of role 

incompatibility: a life event history analysis of family 

roles and marijuana use. American Journal of Sociology 

1985;90(6):1284–1325. 

Zane N, Sasao T. Research on drug abuse among Asian 

Pacific Americans. Drugs & Society 1992;6(3–4):181–209. 

Zbar JD. Marketing to Hispanics; the Spanish-language 

magazine is getting crowded with new entries as 

publishers and advertisers look to reach a growing 

market of 27 million people who spend $228 billion 

annually. Advertising Age 1996;67(12):27–8. 

256 Chapter 4 
Chapter 5
 

Tobacco Control and Education Efforts Among
 

Members of Four Racial/Ethnic Minority Groups
 

Introduction 259
 

Principles for Developing Culturally Appropriate Tobacco Control Strategies 259
 

Information Needs 262
 

Research and Development Limitations 263
 

Primary Prevention Efforts 266
 

Efforts to Restrict Youth Access to Tobacco 266
 

School-Based Health Education Approaches 269
 

Project SMART (Self-Management and Resistance Training) 271
 

Life Skills Training Program 271
 

Project SHOUT (Students Helping Others Understand Tobacco) 271
 

Southwestern Cardiovascular Curriculum Project and Pathways to Health 272
 

Other Primary Prevention and Intervention Efforts 272
 

Mass Media Efforts to Prevent Tobacco Use 273
 

Smoking Cessation Programs 274
 

Self-Help Approaches 275
 

Rompa Con el Vicio: Una Guía Para Dejar de Fumar (Break the Habit:


 A Guide to Stop Smoking) 275
 

Pathways to Freedom 276
  ̧  ̧ Làm Thê’ Nào Dê Bo Hút Thuô’c? (How to Quit Smoking) 276
 

It’s Your Life—It’s Our Future 276
 

Victory Over Smoking—A Guide to Smoking Cessation for You and Your Family 277
 

Smoking: Facts and Quitting Tips Series 277
 

Hot Lines 277
 

Group Approaches 277
 

Community Approaches 278
 

Stanford Five-City Multifactor Risk Reduction Project 279
 

Programa Latino Para Dejar de Fumar (Hispanic Program to Quit Smoking) 279
 

Sí Puedo (Yes, I Can) 280
 

Pathways to Freedom Community Demonstration Project 280
 

Quit Today! 280
 

Chicago Lung Association’s Multifaceted Smoking Cessation Intervention 281
 

Chicago Community-Based Interventions for Low-Income African Americans 281
 

Freedom from Smoking® for You and Your Family on TV/Por Su Salud y


 Su Familia 281
 

A Su Salud (To Your Health) 282
 

University of North Carolina/North Carolina Mutual Quit for Life Guide 282
 

Legends 282
 

Great American Smokeout 283
 

Suc Khoe La Vang! (Health is Gold!) 283
 
 

Involvement of Health Care Providers 283
 

For You and Your Family 284
 

American Indian Cancer Control Project 286
 

Involvement of Employers 286
 

Involvement of Nontraditional Providers 286
 

Environmental Tobacco Smoke and Clean Indoor Air Policies 287
 

Economic Efforts to Reduce Tobacco Use 292
 

Efforts to Control Tobacco Advertising and Promotion 293
 

Tobacco Product Regulations 298
 

Conclusions 299
 

References 301
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Introduction 

Various approaches have been used to prevent 

and control tobacco use among racial/ethnic minority 

groups in the United States. This chapter addresses 

six major approaches to tobacco control: (1) primary 

prevention efforts, (2) smoking cessation programs, 

(3) environmental tobacco smoke (ETS) and clean indoor air policies, (4) economic efforts to reduce tobacco 

use, (5) efforts to control tobacco advertising, and (6) 

tobacco product regulations (Satcher and Eriksen 1994). 

Each section presents a selection of interventions and 

focuses on activities that reflect the specific characteristics of given racial/ethnic groups. 

Because most of these efforts are relatively new 

among racial/ethnic group members and many have 

been developed or applied in predominantly white 

communities, little information is available about the 

ease and feasibility of their implementation or replication in racial/ethnic contexts. Although data exist 

on the overall effectiveness of programs that do not 

differentiate racial/ethnic minority groups from 

whites, data are limited on the effectiveness of racial/ 

ethnic-specific tobacco control efforts, because results 

of their evaluations are just beginning to appear in the 

literature. Although an increasing number of tobacco 

control programs are being implemented among various racial/ethnic groups, many of these programs lack 

evaluation components. To remedy the lack of information, culturally appropriate research and evaluations need to be conducted in the future, and more 

professionals need to be trained in culturally appropriate research and evaluation methodologies. Moreover, the types of tobacco control efforts that are most 

effective, easiest to implement, and most cost-effective 

among racial/ethnic groups must be identified (Fiore 

et al. 1996). In some instances, smoking cessation treatments that have been shown to be effective with nonHispanic whites also have produced positive effects 

with racial/ethnic populations (Fiore et al. 1996). It is 

already well known that preventing tobacco use is of 

paramount importance because cessation is difficult. 

Tobacco control infrastructures in white and 

racial/ethnic minority communities have developed 

differently, although the reasons are not well understood. This development has been influenced by many 

factors: immigration; the historical and current role of 

the tobacco industry in the economic, political, social, 

and cultural life of the community; and the resources 

invested in communities for research and the establishment of tobacco control programs (Robinson et al. 

1995; Shelton et al. 1995). Robinson and colleagues 

developed an index to measure the capacity of racial/ 

ethnic communities to engage in, develop, and implement tobacco control initiatives. The researchers then 

applied the index to racial/ethnic communities on a 

national level. They defined capacity in the index as 

being made up of four broad components, each of 

which is composed of numerous elements: (1) research, 

(2) infrastructure, (3) diffusion of programs, and 

(4) internalization of policy initiatives. The index assumes that a logical order exists among these components, that is, that a community’s ability to gather data 

and assess its needs precedes program development 

and dissemination. During this process, it is likely that 

a community’s capacity grows through the evolution 

of new leaders, establishment of more communication 

networks, and emergence of a deeper understanding 

and acceptance of community needs and interventions 

to meet those needs. Robinson and colleagues (1995) 

concluded that racial/ethnic communities have fewer 

resources and less infrastructure to develop and implement tobacco control initiatives than the white community. In addition, racial/ethnic communities were 

compared with one another, and findings demonstrated variability among communities. The index can 

be considered a preliminary but important step in 

providing a useful framework for evaluating the relative tobacco control capacity of racial/ethnic minority 

communities. Mature tobacco control infrastructures 

provide leadership, advocacy for a smoke-free 

environment, communication systems, established research initiatives, effective tobacco control programs, 

and environmental norms; these elements enable 

communities and their residents to counter tobacco 

industry marketing strategies and the appeal of an 

addictive substance. 

Principles for Developing Culturally 

Appropriate Tobacco Control Strategies 

To be culturally appropriate, interventions must 

properly reflect the characteristics of the group members; that is, programs must recognize that cultural 

groups—whether they are based on race/ethnicity, national origin, or other characteristics—are not monolithic entities. Behavior can be affected by not only 

demographic characteristics, such as gender, employment status, educational level, literacy, income, and 

Tobacco Control and Education Efforts 259 
 

Surgeon General's Report 

age but also such variables as national background (i.e., 

the place of birth of individuals, their parents, or 

grandparents); acculturation (with its correlates of 

generational history, time of migration, and language 

preference); and large social circumstances such as racism, discrimination, and poverty. In particular, and as 

discussed in Chapter 4, tobacco prevention and control strategies must respond to the historical context 

of racial/ethnic communities as well as to their 

current needs (Ellis et al. 1995). Those attitudes and 

behaviors that have been shaped by the historical relationship between the community on one hand and 

tobacco and the tobacco industry on the other need to 

be considered when tobacco control strategies are 

developed. 

Although few tobacco control programs targeting racial/ethnic groups have been culturally appropriate, they are increasing, and their evaluation will 

further guide the development of culturally appropriate tobacco control strategies. Such programs would 

address these racial/ethnic groups’ differing psychosocial and large social factors related to tobacco use. 

Development of culturally appropriate interventions also must go beyond language translations and 

adaptations of materials (e.g., Rogler et al. 1987; Marín 

1993; Bayer 1994) and should do more than simply 

include contemporary, group-specific traditions or 

ancestral symbols and traditions. In addition, planners should not assume that the involvement of community leaders and organizations will automatically 

guarantee a program’s success. Marín (1993, p. 149) 

has argued that to be culturally appropriate, an intervention must meet these requirements: “(1) it is based 

on the cultural values of the group, (2) the strategies 

that make up the intervention reflect the subjective 

culture (attitudes, expectancies, norms) of the group, 

and (3) the components that make up these strategies 

reflect the behavioral preferences and expectations of 

the group’s members.” 

Recent studies have identified numerous intergroup differences in beliefs, attitudes, expectancies, 

and norms that are useful in designing effective tobacco control programs by identifying optimal messages or techniques that are culturally appropriate. 

Racial/ethnic cultural values are often an asset in tobacco control efforts. For example, Marín and colleagues (1990a) found that Hispanic smokers were 

more likely than white smokers to think that an effective motivator to quit smoking was the knowledge that 

adults who smoke set a bad example for children and 

endanger children’s health. According to Robinson 

and colleagues (1992), African Americans responded 

to the use of prayer during smoking cessation 

programs, and Hodge and colleagues showed that 

American Indians were unresponsive to confrontational approaches for curtailing tobacco use (American Indian Cancer Control Project 1991). Materials 

developed for Chinese Americans have offered the use 

of martial arts as a behavioral alternative to cigarette 

smoking (Chinese Community Smoke-Free Project 

1992). Another example of a culturally appropriate 

message is a billboard used by the California Department of Health Services to target Hispanics (Figure 1). 

The billboard makes use of a basic Hispanic value 

(familialism) within the context of a message that is an 

important motivator to Hispanics to quit smoking— 

quitting to protect the health of the family (Marín et 

al. 1989, 1990a). More recently, in an analysis of a population-based survey of Californians 18 years of age and 

older, researchers found that African Americans and 

Hispanics were more likely than whites to plan to quit 

smoking in the near future and to have tried to quit at 

least one time (Kaplan et al. 1993). In a comparison of 

smoking cessation intentions and behaviors among 

white and African American smokers, white smokers 

were more likely to set quitting smoking as a goal, 

whereas African Americans were more likely to focus 

on a goal of reducing the number of cigarettes they 

smoked per day or making other changes in smoking 

behavior (Hahn et al. 1990). Another study found that 

intentions to breast-feed predicted smoking cessation 

among African American pregnant women (O’Campo 

et al. 1992). 

Other recent studies of smoking cessation programs indicate that members of most racial/ethnic 

groups tend to be very interested in quitting smoking. 

In the 1993 National Health Interview Survey (NHIS), 

current smokers in all racial/ethnic groups said they 

were willing to quit smoking (Table 1) (National Center for Health Statistics [NCHS], public use data tape, 

1993). African Americans (71.4 percent) reported the 

desire to quit in greater proportions than members of 

the other racial/ethnic groups, whereas Asian Americans and Pacific Islanders (60.2 percent) showed the 

least interest in quitting. In all four racial/ethnic 

groups, women were more likely than men to want to 

stop smoking. Moreover, data from the Community 

Intervention Trial for Smoking Cessation’s (COMMIT) 

initial survey in 10 U.S. communities showed that 

more African Americans than whites, both men and 

women, said they wanted “a lot” to quit (Royce et al. 

1993). In a San Francisco study, Hispanics considered 

a high interest in quitting smoking to be more desirable than did whites (Marín et al. 1989). 

Despite their interest in smoking cessation, members of these racial/ethnic minority groups have been 

260 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Figure 1. Billboard used by the California Department of Health Services in targeting Hispanics to quit 

smoking* 

*Translation: If you smoke, she smokes.
 

Source: California Department of Health Services, Tobacco Control Media Education Campaign, Sacramento, 1993.
 

Table 1.	 Percentage of adult smokers who would like to stop smoking,* by race/ethnicity and gender, 

National Health Interview Survey, United States, 1993 

African

Americans 

American Indians/ 

Alaska Natives 

Asian Americans/ 

Pacific Islanders Hispanics Whites 

Characteristic % ±CI† % ±CI % ±CI % ±CI % ±CI 

Total 71.4 4.8 65.0 14.6 60.2 12.2 68.7 5.8 70.4 1.8 

Men 68.6 7.3 57.3 23.4 58.3 14.6 63.8 7.8 67.8 2.6 

Women 74.9 5.4 70.3 16.1 65.3 22.6 79.3 8.1 72.4 2.1 

*In response to the question, “Would you like to completely stop smoking cigarettes?”

†95% confidence interval.
 

Source: National Center for Health Statistics, public use data tape, 1993.
 

less likely than whites to actually quit. In a study of 

786 adult smokers in the Minneapolis-St. Paul area, 

Hahn and colleagues (1990) found that 52 percent of 

African American men had tried to quit smoking in 

the previous year, compared with 63 percent of white 

men. They also found that 56 percent of African American women had tried to quit, compared with 58 percent of white women. In a recent survey conducted in 

California, African Americans, Asian Americans, and 

Hispanics were more likely than whites to report that 

they tried to quit smoking in the previous year; however, relapses were more common among African 

Americans (49.5 percent), Asian Americans (39.8 percent), and Hispanics (37.8 percent) than among whites 

(35.0 percent) (Burns and Pierce 1992). NHIS data from 

1991 that were statistically adjusted for gender, age, 

education, and poverty status indicate that African 

Americans and Hispanics were more likely than whites 

to quit for a day during the previous year but that African Americans who tried to quit were more likely 

than whites to relapse (Centers for Disease Control and 

Prevention [CDC] 1993b). In another study— 

conducted in Milwaukee, Wisconsin; Minneapolis, 

Minnesota; and Seattle and Spokane, Washington— 

Tobacco Control and Education Efforts 261 
 

Surgeon General's Report 

American Indians who were patients at Indian Health 

Service (IHS) clinics reported a moderate desire to quit 

smoking (mean of 5.97 on a scale of 0 to 10) but a high 

rate of relapse (70 percent) (Lando et al. 1992). These 

data suggest the need for culturally appropriate programs that not only help smokers stop smoking but 

also support them in their efforts to maintain a smokefree lifestyle and to avoid relapses. 

In addition to considering intergroup differences, 

tobacco control programs targeting members of racial/ 

ethnic groups must involve culturally competent 

staff—persons with the academic and interpersonal 

skills needed to understand and appreciate racial/ 

ethnic groups’ cultural differences and similarities and 

to respect these groups’ beliefs, attitudes, norms, and 

behaviors (Cross et al. 1989; Roberts 1990; Orlandi 

1992). Such staff must have the skills to understand 

their own cultural beliefs and values, to understand 

the dynamics of cultural differences, and to translate 

that understanding into culturally appropriate behaviors. Cross and colleagues (1989) and Davis and 

Voegtle (1994) propose that culturally competent health 

care systems—and by implication culturally competent staff—should (1) be aware and accepting of 

cultural differences, (2) have the capacity for cultural 

self-assessment, (3) be conscious of the dynamics inherent when cultures interact, (4) have relevant cultural knowledge of the targeted group, and (5) have 

skills that promote adaptation to diversity. Other authors, such as Corcoran and Robinson (1994), assert that 

public health professionals need to actively include the 

community by establishing planning teams composed 

of key community leaders and that staff be willing to 

redefine the project as community needs change. 

Furthermore, persons designing and implementing tobacco control programs ideally should determine 

whether theoretical models and approaches originally 

developed for certain populations would be relevant 

to the racial/ethnic groups being targeted. Most current theoretical approaches to health promotion have 

been developed by white researchers who work primarily with white populations. Some researchers have 

questioned the overall validity and usefulness of these 

theoretical approaches because the approaches that are 

developed do not necessarily reflect the cultural 

values shared by other racial/ethnic groups and do 

not consider how variables such as acculturation, racism, and poverty may affect peoples’ health behaviors 

(Prochaska 1992; Robinson and Sutton, in press). This 

concern can be addressed only through an empirical 

approach that analyzes the usefulness of theories initially developed for groups other than the ones being 

targeted by an intervention (Orlandi 1992). 

Information Needs 

To ensure that prevention and cessation programs 

will provide members of a racial/ethnic minority group 

with the information that they need most, program 

designers must find out three things. (1) Do members 

of the community need basic information about the 

harmful health effects of tobacco use? (2) What culturespecific experiences directly influence the role of tobacco 

and the tobacco industry and how can they be addressed 

in health promotion messages? (3) Which media and 

information sources would be most effective in conveying information to the targeted group? 

Because information about the dangers of cigarette 

smoking has been provided to the public for more than 

30 years, most U.S. citizens and residents are well aware 

of these health consequences. American Indians, for example, tend to have a high level of knowledge about the 

hazards of smoking. In a study of 1,369 northern California American Indians who were patients at IHS clinics, Hodge and colleagues (1995) found that most American Indians knew about the health effects of tobacco use, 

particularly its relationship with cancer and the dangers 

of smoking while pregnant. 

Conversely, this basic information may not have 

reached persons who have limited English proficiency, 

who have recently arrived in the United States, or who 

may not have been exposed to media and information 

sources that traditionally have carried messages about 

the dangers of cigarette smoking. It is possible for example, that Asian Americans, Pacific Islanders, and 

Hispanics who have recently immigrated to the United 

States are not familiar with the dangers of cigarette 

smoking. Less acculturated Asian Americans, Pacific 

Islanders, and Hispanics who have resided in the 

United States for several years may not have benefited 

from large-scale public education campaigns directed 

at persons who are proficient in English and those who 

interact frequently with mainstream society. To help 

address this need, the Agency for Health Care Policy 

and Research translated the consumer cessation guide 

“You Can Quit Smoking” into Cambodian, Laotian, 

Vietnamese, Tagalog, Korean, and Chinese (U.S. Department of Health and Human Services [USDHHS] 1996 

and 1997). Chen and colleagues (1993) reported that less 

than 40 percent of Cambodian, Laotian, and Vietnamese smokers in Columbus, Ohio, had heard that smoking caused heart disease. Earlier, Jenkins and colleagues 

(1990) reported that only 74 percent of Vietnamese 

adults surveyed in San Francisco knew that smoking 

caused cancer. Nevertheless, Campbell and Kaplan 

(1997) found that both less acculturated and more acculturated Hispanic women (as measured by language 

orientation) agreed that cigarette smoking is harmful 

262 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

to children’s health. However, less acculturated Hispanic women were more likely to agree that it is safe to 

smoke for a year or two. 

Even long-term U.S. residents who have been 

receiving information on the dangers of tobacco smoke 

for many years may have limited or incorrect information. For example, in a study of Chicago women 

living in subsidized housing, 46 percent of African 

American women agreed that the chances of getting 

lung cancer were the same for smokers and nonsmokers, compared with 27 percent of white women 

(Manfredi et al. 1992). In that study, African American women also reported that the causes of lung cancer were unknown or that lung cancer was the result 

of environmental pollution (Lacey et al. 1993). Conversely, in a multivariate analysis, African Americans 

compared with whites were found to have higher levels of knowledge about the benefits of not using tobacco and the health consequences of tobacco use, but 

blue collar status emerged as the most significant predictor of lower levels of knowledge (Robinson et al. 

1991). In another study, African American residents 

of urban Missouri areas recognized the harmful effects 

of ETS but were less likely than whites to know the 

health risks associated with active smoking, particularly its link with heart disease (Brownson et al. 1992). 

In a 1989 survey of Hispanic and white clients of 

a San Francisco health maintenance organization 

(HMO), Hispanics had numerous misconceptions 

about the causes of cancer, but a similar proportion of 

Hispanics (97.5 percent) and whites (98.4 percent) 

knew that cigarette smoking caused cancer (PérezStable et al. 1992). Similarly, Vander Martin and 

colleagues (1990) surveyed patients of primary care 

physicians and found that African Americans (87.8 

percent) and Asian Americans (86.5 percent) were 

significantly less likely than whites (92.1 percent) and 

Hispanics (91.6 percent) to recognize that cigarettes 

had harmful health effects. They also found that African American (58.9 percent), Asian American (56.3 percent), and Hispanic (60.1 percent) smokers were less 

likely than white smokers (80.3 percent) to recognize 

that they were addicted to cigarettes. In the 1992 NHIS, 

members of racial/ethnic groups were generally less 

likely than whites to indicate concern over the carcinogenic characteristics of cigarette smoking, although 

they expressed the same level of agreement as whites 

regarding the need for pregnant women not to smoke 

and about the harmfulness of ETS (Table 2) (NCHS, 

1992 Cancer Control Supplement, public use data 

tape). In addition, racial/ethnic group members were 

less likely than whites to believe that there were health 

benefits to quitting smoking. 

Once program planners decide what information 

needs to be conveyed, they must consider which media would be most effective in reaching the targeted 

audience. Many researchers have suggested employing the media most frequently used by the targeted 

ethnic group. To reach African American smokers, for 

example, Stotts and colleagues (1991) suggest that 

smoking cessation programs should use African 

American broadcast and print media to address this 

group’s information and motivational needs. 

Moreover, prevention and cessation programs 

should use the information channels (e.g., radio, television, and newspapers) and information sources (e.g., 

physicians, peers, and actors) that members of the 

targeted racial/ethnic group perceive to be trustworthy and reliable. Unfortunately, little is known about 

how credible the various media and information 

sources are perceived to be by members of racial/ 

ethnic groups. In one of the few studies focusing on 

this issue—research involving African Americans in 

Columbia, South Carolina; Durham, North Carolina; 

Hartford, Connecticut; and Springfield, Massachusetts—television was perceived as the most trustworthy information channel (by 70 percent of participants), 

followed by newspapers (59 percent), radio (53 percent), and magazines (53 percent) (Cernada et al. 1989– 

1990). A recent study among Hispanics (Marín 1996) 

showed that the most credible channels for disseminating information about cigarette smoking among 

Hispanics are (in descending order) books, newspaper articles, pamphlets, magazine articles, and television news shows; the least credible were fotonovelas 

(illustrated comic-book type of booklet targeting 

adults) and telenovelas (Spanish-language soap operas). 

The same study found that the most credible sources 

of cigarette smoking information among Hispanics 

were (in descending order) a physician, a cancer patient, and a peer of the respondent; the least credible 

sources of information were a politician, a singer, an 

actor, and a child. 

Research and Development Limitations 

In a recent analysis of racial/ethnic minority 

groups’ expertise for engaging in tobacco control efforts, Robinson and colleagues (1995) suggested that 

African American, American Indian, Alaska Native, 

Asian American, Pacific Islander, and Hispanic groups 

all have been significantly limited in conducting research and developing program and policy initiatives 

for tobacco control. According to Robinson and colleagues, these limitations may exist, in part, because 

racial/ethnic groups tend to have fewer resources for 

tobacco control activities than whites. 

Tobacco Control and Education Efforts 263 
264 Chapter 5 

Surgeon General's Report 

Table 2.	 Adults’ beliefs about the health effects of smoking, by race/ethnicity, gender, and smoking status, 

National Health Interview Survey, United States, 1992 

African American Indians/ Asian Americans/ 

Americans Alaska Natives Pacific Islanders Hispanics Whites ____________ ________________ _______________ _____________ ___________ 

Characteristic % ±CI* % ±CI % ±CI % ±CI % ±CI

 So many things cause cancer that it does not really matter if you smoke. 

Overall 

Total 28.6 3.0 25.6 9.6 27.3 7.0 30.7 3.0 16.5 1.0 

Men 27.8 4.7 30.7 14.1 25.2 10.5 28.1 4.3 18.0 1.5 

Women 29.3 3.6 21.3 11.3 29.3 8.4 33.2 3.9 15.2 1.2 

Nonsmokers 

Total 25.2 3.6 18.7 7.8 22.9 6.6 25.4 3.1 10.9 1.0 

Men 23.7 6.2 19.9 14.6 15.3 9.2 23.3 4.6 11.8 1.5 

Women 26.3 4.1 17.7 11.0 28.1 8.6 27.3 4.1 10.0 1.2 

Smokers 

Total 38.2 5.6 39.4 21.9 47.6 18.9 50.5 7.0 32.5 2.3 

Men 36.4 7.9 54.1 28.5 45.9 21.0 43.3 9.2 33.7 3.2 

Women 40.2 7.3 27.4 24.2 64.9 34.7 58.8 9.9 31.2 3.1 

Smoking by a pregnant woman may harm the baby. 

Overall 

Total 90.7 1.7 90.8 6.1 92.3 3.9 92.0 1.9 92.5 0.7 

Men 90.5 2.6 86.0 10.4 91.9 6.3 92.9 2.7 91.4 1.0 

Women 90.9 2.0 94.9 6.4 92.6 4.7 91.2 2.4 93.5 0.8 

Nonsmokers 

Total 92.6 1.7 94.5 5.2 92.2 4.5 93.2 2.0 94.9 0.6 

Men 92.2 2.7 87.8 10.5 91.1 8.8 92.5 3.2 93.7 1.0 

Women 92.9 2.2 100.0 0.0 93.0 4.8 93.8 2.4 96.0 0.7 

Smokers 

Total 90.1 2.9 89.1 11.6 94.3 6.1 92.1 4.2 89.5 1.5 

Men 90.1 4.0 92.7 14.3 95.6 6.1 95.0 4.7 88.5 2.2 

Women 90.2 3.8 86.2 17.4 81.2 24.7 88.8 6.9 90.5 1.8 

The smoke from other people’s cigarettes is harmful to you. 

Overall 

Total 82.1 2.2 79.8 9.1 80.3 6.2 86.7 2.2 85.2 0.9 

Men 81.5 3.4 77.1 16.2 83.8 7.4 85.4 3.4 82.8 1.4 

Women 82.7 2.7 82.2 10.9 76.9 9.4 87.9 2.7 87.4 1.1 

Nonsmokers 

Total 89.7 2.0 94.9 4.2 81.1 7.1 89.8 2.3 91.6 0.8 

Men 90.0 3.2 92.8 6.0 86.1 9.4 88.9 3.5 89.7 1.3 

Women 89.4 2.4 96.6 6.5 77.6 9.8 90.6 2.8 93.4 0.9 

Smokers 

Total 66.8 5.2 57.6 20.8 78.4 11.7 80.0 5.1 71.0 2.2 

Men 67.8 7.0 57.8 29.7 80.6 12.5 76.3 7.9 68.4 3.1 

Women 65.7 7.5 57.4 29.5 56.4 36.4 84.3 6.1 73.7 2.9 

*95% confidence interval.
 

Source: National Center for Health Statistics, 1992 Cancer Control Supplement, public use data tape.
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 2. Continued 

African American Indians/ Asian Americans/ 

Americans Alaska Natives Pacific Islanders Hispanics Whites ____________ ________________ _______________ _____________ ___________ 

Characteristic % ±CI % ±CI % ±CI % ±CI % ±CI

 Most deaths from lung cancer are caused by cigarette smoking. 

Overall 

Total 73.7 2.9 79.3 10.4 77.1 6.1 77.4 2.8 75.0 1.1 

Men 74.9 4.6 75.5 15.6 79.9 8.4 76.7 4.3 73.9 1.7 

Women 72.8 3.4 82.6 10.5 74.3 8.7 78.2 3.5 76.1 1.3 

Nonsmokers 

Total 80.0 2.9 84.6 9.0 79.1 6.8 79.4 3.2 81.7 1.1 

Men 81.6 5.2 71.2 18.0 83.4 10.2 78.5 4.9 80.3 1.7 

Women 78.8 3.5 95.6 5.8 76.1 8.8 80.3 3.7 82.9 1.4 

Smokers 

Total 61.5 5.6 74.1 18.4 69.4 14.2 73.8 6.2 59.8 2.3 

Men 64.6 7.6 91.2 16.8 74.5 14.6 71.8 8.8 60.4 3.5 

Women 57.7 7.7 60.3 28.6 19.1 25.3 76.2 7.8 59.3 3.1

 Even if a person has smoked for more than 20 years, there is a

 health benefit to quitting. 

Overall 

Total 82.6 2.5 81.3 9.1 78.2 6.3 80.9 2.9 91.4 0.4 

Men 82.0 3.9 80.7 11.2 78.6 8.7 82.0 4.2 91.1 1.0 

Women 83.0 3.0 81.7 14.1 77.8 9.1 79.8 3.5 91.7 0.9 

Nonsmokers 

Total 85.5 2.8 79.6 12.3 78.9 7.1 82.1 3.1 93.9 0.7 

Men 85.5 4.6 81.8 11.9 80.6 10.8 82.2 4.6 94.0 1.0 

Women 85.4 3.3 77.8 19.8 77.7 9.3 82.1 3.9 93.8 1.0 

Smokers 

Total 79.0 4.5 88.2 11.0 76.6 13.1 80.3 5.8 88.0 1.7 

Men 77.7 6.8 87.8 17.0 76.0 14.6 82.9 8.2 86.9 2.4 

Women 80.7 5.9 88.5 14.0 81.9 24.3 77.2 8.0 89.2 2.0 

Overcoming these limitations will be imperative 

in future years because the need for culturally appropriate tobacco control programs will likely grow. 

Numerous researchers have argued that culturally appropriate health promotion efforts need to be developed for racial/ethnic groups (Rogler et al. 1987; 

Edwards and MacMillan 1990; Nestle and Cowell 1990; 

Gonzalez et al. 1991; Robinson et al. 1991; Uba 1992; 

Vega 1992; Alcalay et al. 1993; Marín 1993). Early outcome data on interventions targeting racial/ethnic 

groups further indicate the need for such strategies 

(Chen et al. 1994; Pérez-Stable et al. 1994; Marín and 

Pérez-Stable 1995). Moreover, in a National Cancer 

Institute (NCI) analysis of self-guided strategies for 

smoking cessation, Glynn and colleagues (1990) supported the need for targeted programs and suggested 

that the availability of self-guided smoking cessation 

materials tailored to the needs of a racial/ethnic group 

“enhances their adoption and may positively affect 

quit rates” (p. 11). Therefore, culturally appropriate 

interventions may prove to be more acceptable and 

easier to implement and also may have increased effectiveness (Fiore et al. 1996). Cultural values, in fact, often 

support the messages given in effective tobacco control 

programs. In addition, if the development process includes community leaders and researchers who represent the community, the process itself will enhance the 

existing tobacco control infrastructure (Robinson et al. 

1995). 

Tobacco Control and Education Efforts 265 
 

Surgeon General's Report 

Primary Prevention Efforts 

Most of the programs that seek to prevent tobacco 

use among racial/ethnic minority groups focus on 

children and adolescents. These interventions include 

efforts to restrict minors’ access to tobacco products, 

school-based health education programs, and mass 

media efforts. 

Efforts to Restrict Youth Access to Tobacco 

A comprehensive national effort to address the 

problem of minors’ access to tobacco was made in 1992 

with the passage of the Synar Amendment to the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (Public Law 102–321), which 

amended the Public Health Service Act. The draft 

regulations were made final in 1996. These regulations require the 50 states, the District of Columbia, 

and U.S. jurisdictions to enact and enforce legislation 

restricting the sale and distribution of tobacco products to minors, as a condition of receiving federal block 

grant funds for substance abuse and treatment. As a 

result, all states now designate an agency to enforce 

their minimum-age laws on purchase of tobacco products. Many local governments have attempted over 

the years to limit access to tobacco among youths under the age of 18 years by enacting or strictly enforcing legislation that limits minors’ ability to purchase 

tobacco over the counter and through vending 

machines, whereas others have opted to educate retailers and encourage them to voluntarily comply with 

legislation that limits the sale of tobacco products to 

minors (Lynch and Bonnie 1994; USDHHS 1994). Studies show that over-the-counter sales of tobacco to 

adolescents under the age of 18 years are indeed widespread, although all states prohibit such sales (Altman 

et al. 1989; Jason et al. 1991; NCI 1991; DiFranza and 

Brown 1992; Forster et al. 1992). Despite laws in every 

state that prohibit the sale of tobacco products to persons under 18 years of age, underage buyers in 1996 

were able to purchase tobacco products from retail 

outlets a median of 40 percent of the time, according 

to reports from states, compared with rates ranging 

from 60 to 90 percent in previous studies (USDHHS 

1998). 

In addition to requirements of the Synar Amendment, the recent regulations on tobacco products proposed by the Food and Drug Administration (FDA) 

and made final on August 23, 1996, sought to reduce 

both minors’ access to tobacco products and the 

appeal those products have to minors (see Efforts to 

Control Tobacco Advertising and Promotion later in 

this chapter). Three key provisions address minors’ 

access to tobacco: (1) requiring vendors to check a photograph identification as proof of age and prohibiting 

sales to those under age 18, (2) prohibiting most vending machines and self-service displays of cigarettes 

except in facilities totally inaccessible to persons under age 18, and (3) prohibiting free samples of cigarettes and sales of individual cigarettes or packs of 

fewer than 20 cigarettes (so-called kiddie packs). Both 

the Synar Amendment and the FDA regulations hold 

promise for reducing tobacco use by all young people, 

including those who are members of racial/ethnic 

groups. 

In general, adults in the four racial/ethnic groups 

perceive that minors have fairly easy access to tobacco 

products. In the 1992–1993 Current Population Survey,1

 a greater proportion of white respondents (55.6 

percent) said that it was very easy for minors to purchase tobacco products, compared with American Indians and Alaska Natives (52.6 percent), Hispanics (49.8 

percent), African Americans (49.0 percent), and Asian 

Americans and Pacific Islanders (44.3 percent) (Table 

3) (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992–1993). Men and nonsmokers were more likely than women and smokers to 

think that minors had easy access to tobacco products. 

Data from the 1989 Teenage Attitudes and Practices 

Survey (TAPS) showed that most youths 12–18 years 

old who reported cigarette smoking bought their cigarettes primarily at small stores or through cigarette 

vending machines (Allen et al. 1993). For example, 86.9 

percent of white adolescents reported often or sometimes buying their cigarettes from small stores, compared with 80.0 percent of African Americans and 90.0 

1 The Current Population Survey (CPS) is a continuous monthly 

survey conducted by the U.S. Bureau of the Census and focuses 

primarily on labor force indicators for the civilian noninstitutionalized U.S. population aged 15 years and older. Questions on 

smoking and tobacco use (NCI Tobacco Use Supplement) were 

added to the CPS for the September 1992, January 1993, and May 

1993 surveys. About 57,000 eligible households are surveyed 

each month and yield approximately 110,000 interviews; 

interviews are conducted with a knowledgeable household 

respondent who responds for all household members aged 15 

years and older. The knowledge, attitude, and belief questions 

described in this report were asked only of self-respondents. 

266 Chapter 5 
Tobacco Control and Education Efforts 267 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

percent of Hispanics. In contrast, 51.4 percent of white 

smokers reported often or sometimes buying cigarettes 

from large stores, compared with 56.6 percent of Hispanics and 39.8 percent of African Americans. 

and age showed that African Americans were less 

likely than whites to have ever been asked to show 

proof of age when buying or trying to buy cigarettes; 

Hispanics were less likely than non-Hispanics to ever 

have been asked to show proof of age (CDC 1996). 

In 1989, 12- to 17-year-old whites who smoked were 

Data from a 1993 follow-up survey (TAPS-II) that 

were statistically adjusted for participant correlation 

Table 3.	 Adults’ beliefs about minors’ ease in purchasing cigarettes and other tobacco products,* by race/ 

ethnicity, smoking status, and gender, Current Population Survey, United States, 1992–1993 

African 

Americans 

American Indians/ 

Alaska Natives 

Asian Americans/
 

Pacific Islanders Hispanics Whites
 

Characteristic % ±CI† % ±CI % ±CI % ±CI % ±CI 

Total 

Very easy 49.0 0.7 52.6 3.3 44.3 1.6 49.8 0.9 55.6 0.3 

Somewhat easy 15.4 0.5 15.9 2.4 16.6 1.2 15.4 0.6 17.6 0.2 

Men 

Very easy 52.5 1.2 55.6 4.9 46.0 2.3 51.9 1.3 57.4 0.4 

Somewhat easy 16.1 0.9 14.5 3.5 17.6 1.8 15.7 1.0 18.7 0.3 

Women 

Very easy 46.8 0.9 50.1 4.5 42.6 2.2 48.1 1.2 54.0 0.4 

Somewhat easy 14.9 0.7 17.0 3.4 15.7 1.6 15.2 0.9 16.7 0.3 

All nonsmokers 

Very easy 50.9 0.9 51.4 4.2 44.1 1.7 50.4 1.0 57.2 0.3 

Somewhat easy 16.1 0.6 16.2 3.1 17.2 1.3 15.5 0.7 17.9 0.2 

All smokers 

Very easy 44.2 1.4 54.2 5.3 45.5 4.1 47.1 2.1 50.9 0.6 

Somewhat easy 13.4 1.0 15.4 3.8 13.8 2.8 15.1 1.5 17.0 0.4 

Nonsmokers 

Men 

Very easy 54.8 1.4 52.2 6.6 46.4 2.6 53.3 1.5 58.9 0.5 

Somewhat easy 16.7 1.0 14.3 4.6 18.5 2.0 15.6 1.1 19.0 0.4 

Women 

Very easy 48.6 1.1 50.7 5.6 42.3 2.3 48.3 1.3 55.7 0.4 

Somewhat easy 15.7 0.8 17.5 4.2 16.1 1.7 15.5 0.9 16.9 0.3 

Smokers 

Men 

Very easy 47.8 2.1 59.3 7.4 45.4 4.9 47.7 2.7 53.6 0.8 

Somewhat easy 14.8 1.5 14.9 5.3 14.9 3.5 16.3 2.0 18.0 0.6 

Women 

Very easy 41.0 1.9 49.1 7.5 45.8 7.5 46.4 3.3 48.4 0.8 

Somewhat easy 12.2 1.3 15.9 5.5 11.3 4.7 13.2 2.3 16.0 0.6 

*In response to the question, “In your opinion, how easy is it for minors to buy cigarettes and other tobacco 

products in your community?” Response categories included “very easy,” “somewhat easy,” “somewhat 

difficult,” “very difficult,” and “don’t know.” 

†95% confidence interval.
 

Source: U.S. Bureau of the Census, public use data tapes, 1992–1993.
 
 

Surgeon General's Report 

more likely (58.7 percent) than same-aged African 

Americans who smoked (43.3 percent) to report that 

they usually bought their own cigarettes. By 1993, 

however, 62.1 percent of whites who smoked and 64.1 

percent of African Americans who smoked reported 

that they usually bought their own cigarettes. In 1989, 

12- to 17-year-old non-Hispanics who smoked were 

more likely (59.0 percent) than Hispanics of the same 

age who smoked (41.3 percent) to report that they usually bought their own cigarettes. By 1993, however, 

62.4 percent of non-Hispanics who smoked and 59.1 

percent of Hispanics who smoked reported that they 

usually bought their own cigarettes (CDC 1996). In a 

study in San Bernardino and Riverside Counties, California, Klonoff and colleagues (1994) found that the 

purchase of single cigarettes by minors was more frequent in ethnic communities (71.2 percent of minors) 

than in white neighborhoods (34.4 percent of minors). 

Klonoff and colleagues (1997) used a factorial 

design to study the sale of cigarettes to minors in 72 

stores in African American, Hispanic, and white communities. Purchase attempts (N = 1,296) were made 

in 24 stores in each community. There were two participants in each age (ages 10, 14, and 16 years), 

gender, and race/ethnicity category. 

Sales were made most often to 16-year-old African 

Americans, regardless of gender. A gender effect existed for Hispanics, and more frequent sales occurred 

to Hispanic girls. Another report based on the same 

data analyzed purchase attempts by 14- and 16-year-old 

African American and white participants in African 

American and white communities (Landrine et al. 1997). 

Racial- and ethnic-specific sales rates were similar in 

white communities. In African American communities, 

however, sales rates were higher for African American 

youths than for white youths. Of the 41 packs of cigarettes sold to African American youths, only 7 percent 

were sold by African American vendors. The rest were 

sold by Asian (67 percent), white (13 percent), and Hispanic (13 percent) vendors, according to participants' 

reports. Unfortunately, vendor-specific sales rates and 

comparable sales data by vendor race/ethnicity for the 

white community were not provided. A limitation of 

this study is that the apparent age of the minors, an important correlate of sales (DiFranza et al. 1996), was not 

assessed by independent raters. 

A community-based study conducted after passage and enforcement of legislation limiting minors’ 

access to tobacco products showed a reduction in the 

proportion of merchants who sell cigarettes to minors 

and the proportion of adolescents who smoke (Jason 

et al. 1991; Jason et al. 1996). Nevertheless, many 

merchants—fully aware of legislation prohibiting sales 

of tobacco to minors—continue to sell these products 

to underage customers. For example, in a 1991 study 

of 156 tobacco retailers in central Massachusetts, 80 

percent of the merchants who displayed statemandated warning signs specifying that it was illegal 

for minors to purchase tobacco products were still willing to illegally sell cigarettes to youths (DiFranza and 

Brown 1992). Likewise, a 1994 Massachusetts study 

reported the ineffectiveness of the tobacco industrysponsored “It’s the Law” voluntary compliance 

program for stores to prevent underage youths from 

purchasing tobacco (DiFranza et al. 1996). The results 

of surveys and sting operations conducted by community action groups affiliated with such organizations as Stop Teenage Addiction to Tobacco (STAT) 

show that before public awareness campaigns, 32 to 

87 percent of U.S. adolescents who tried to buy cigarettes in various communities were able to do so. These 

figures decreased dramatically (by 10 to 93 percent) 

when merchants were informed of the law, fined for 

selling tobacco products to minors, or told that their 

behavior would be monitored by law enforcement 

agents (Altman et al. 1989; Feighery et al. 1991; Forster 

et al. 1992). 

Some of the campaigns aimed at increasing merchants’ awareness of the law’s provisions have concentrated on small, urban convenience stores where 

many youths purchase their own cigarettes (Davis 

1991). As a result of a merchant public awareness campaign in San Diego County, tobacco sales to minors 

declined in Hispanic and Asian American neighborhoods but not in African American communities (Keay 

et al. 1993). Additional data are needed to determine 

the reasons that shopkeepers sell tobacco to minors 

(Landrine et al. 1994) and also the effectiveness of various approaches among youths of different racial/ 

ethnic minority groups and among owners of convenience stores located in racial/ethnic neighborhoods. 

Information about the tobacco-purchasing patterns 

among youths of various racial/ethnic groups also is 

limited; additional research in this area would be particularly useful in designing programs to curtail 

youths’ access to tobacco products. 

Cigarette vending machines are another way 

minors obtain tobacco products, because the machines 

are rarely supervised by adults. Tobacco control advocates have recommended banning cigarette vending machines, locking them, or moving them to places 

where adults could check the ages of purchasers. Results from the 1992 California Tobacco Survey showed 

that a large proportion of Hispanics (93.8 percent), 

African Americans (91.1 percent), Asian Americans 

and Pacific Islanders (87.9 percent), and whites (84.2 

268 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

percent) were willing to ban cigarette vending machines that are accessible to minors (Pierce et al. 1994a). 

Strong support for banning cigarette vending 

machines accessible to youths also was found in the 

1994 Robert Wood Johnson Foundation (RWJF) Youth 

Access Survey, a national household survey to assess 

public attitudes about policy alternatives for limiting 

youths’ access to tobacco products. This survey of 

2,345 adults, including 486 African Americans, 402 

Hispanics, and 1,341 whites, showed that there was 

willingness to ban cigarette vending machines accessible to youths (Table 4) and strong support for banning all cigarette vending machines (Nancy Kaufman 

et al., unpublished data). 

Although most adults believe that it is relatively 

easy for youths to obtain cigarettes, the RWJF Youth 

Access Survey found that African Americans (57.5 

percent) were somewhat less likely than Hispanics 

(67.4 percent) and whites (70.0 percent) to believe that 

tobacco products were very or somewhat easy for 

youths to buy in their communities. Even so, African 

Americans and Hispanics were more supportive than 

whites of increasing retailing restrictions that would 

limit youths’ access to tobacco, with Hispanics being 

the most supportive. The retail measure with the 

broadest public support is the proposal to eliminate 

self-service tobacco displays, requiring retailers to keep 

tobacco products behind the counter. Hispanics and 

African Americans differ from whites in their beliefs 

about the potential results of raising the age at which 

tobacco products can be legally purchased. Sixty-five 

percent of Hispanics and 61.4 percent of African Americans, compared with only 44.3 percent of whites, believe that raising the age of legal purchase to 21 would 

prevent smoking initiation. Similar results were 

observed when 19 was proposed as the legal age of 

purchase. 

School-Based Health Education 

Approaches 

In the past decade, numerous programs to prevent tobacco use have been developed for use in 

schools with a substantial number of white students 

(Lynch and Bonnie 1994). Rather than consider the 

specific cultural characteristics of targeted students, 

most of these programs have been theory-driven or 

intuitively designed and directed toward students at 

large. Although youths from various racial/ethnic 

groups have been included in numerous studies, their 

responses and behaviors have rarely been separately 

analyzed or reported in the literature. In a review of 

school-based smoking-prevention programs, an NCI 

panel of experts concluded that, in general, children 

from the major racial/ethnic groups and those of lowsocioeconomic status were the least likely to have been 

reached by smoking-prevention programs in schools 

(Glynn 1989). In 1991, the NCI Advisory Panel on 

Tobacco-Use Reduction Among High-Risk Youth 

(Glynn et al. 1991) recommended that entire schools 

be the target of efforts to identify high-risk youth and 

that a broader approach (such as identifying a school 

with a large proportion of economically disadvantaged 

youth) may be more cost-effective and reach the greatest number of high-risk youth without detrimentally 

labeling individuals the way a more focused approach 

might. To support the development of effective schoolbased interventions, the CDC published a set of guidelines for school health programs to prevent tobacco 

use and addiction (CDC 1994). These guidelines 

incorporate findings from a number of studies on 

tobacco use and addiction, call for school-based 

tobacco-use prevention programs to be provided for students from all racial/ethnic groups, and indicate that 

such programs should be “sensitive to, and representative of, a student population that is multicultural, 

multiethnic, and socio-economically diverse” (p. 4). 

One significant challenge is the difficulty of 

implementing a targeted, culturally appropriate intervention in a typical urban classroom that includes students from many cultural and racial/ethnic groups. 

Another problem with school-based interventions is 

that teachers in most school districts are overworked 

and do not have the time, resources, or training to perform these additional activities as part of their daily 

lessons (Perry et al. 1990). Teachers often have difficulty making tobacco control a high-priority area for 

instruction when they must also deal with basic educational issues and serious community problems such 

as crime, illegal drug use, and substandard housing. 

In addition, high dropout rates in some racial/ethnic 

minority communities make it impossible for schoolbased programs to reach many children. For example, 

a recent analysis of 1990 census data (U.S. General 

Accounting Office [GAO] 1994) showed that a large 

proportion of Hispanic dropouts have abandoned formal schooling within the grades (sixth through ninth) 

when adolescents are vulnerable to cigarette smoking 

initiation (USDHHS 1994). The GAO report showed 

that among all Hispanic dropouts, 14 percent had left 

formal school by the fourth grade and 56 percent had 

left by the ninth grade. 

To overcome these challenges, new school-based 

tobacco control programs continue to be developed 

and implemented. ASSIST, the American Stop Smoking Intervention Study, for example, has a youth component, and at some sites such as North Carolina, the 

Tobacco Control and Education Efforts 269 
 

Surgeon General's Report 

Table 4.	 Public support for and beliefs about policies regarding tobacco access and marketing, by selected 

characteristics, Robert Wood Johnson Foundation Youth Access Survey, 1994 

African American* 

(N = 486) 

Hispanic 

(N = 402) 

White* 

(N = 1,341) 

Characteristic % ±CI† % ±CI % ±CI 

Favor banning the sale of cigarettes 

in vending machines 74.9 3.5 84.5 3.1 72.5 3.1 

Favor banning cigarette vending 

machines that are accessible to youths 93.7 2.0 93.0 2.2 90.7 2.0 

Think retailers should keep tobacco 

products behind the counter to prevent 

shoplifting by minors 82.6 3.0 88.9 2.7 75.5 3.0 

Favor allowing the sale of cigarettes only in 

certain stores, just as is done with alcohol 46.9 4.0 72.9 3.9 43.1 3.4 

Believe that restricting the sale of cigarettes 

to persons aged 21 years and older will help 

reduce the number of kids under 21 who 

begin smoking 61.4 3.9 65.4 4.2 44.3 3.4 

Believe that restricting the sale of cigarettes 

to persons aged 19 years and older will help 

reduce the number of kids in high school 

who begin smoking 56.9 3.9 66.5 4.1 47.1 3.5 

Favor banning tobacco product 

advertising on billboards 61.8 3.9 68.9 4.1 57.3 3.4 

Favor banning tobacco product advertising 

in newspapers or magazines 57.4 3.9 62.3 4.3 49.1 3.5 

Think tombstone advertising would 

make smoking less appealing to youths 72.1 3.6 74.9 3.8 72.8 3.1 

Favor requiring plain packaging to make 

cigarettes less attractive to youths 48.0 4.0 61.8 4.3 44.9 3.5 

Favor not allowing coupons in cigarette packs 

to obtain promotional items appealing to youths 76.5 3.4 82.1 3.4 67.8 3.3 

Favor not allowing coupon promotions 

to obtain free cigarettes by mail 79.5 3.2 89.8 2.7 80.4 2.8 

Favor not allowing tobacco companies to sponsor 

sporting or entertainment events in which 

their brand names are featured 65.1 3.8 71.7 3.9 51.9 3.5 

Think that it is very or somewhat easy 

for youths to buy cigarettes 57.5 3.9 67.4 4.1 70.0 3.2 

*Non-Hispanic. 

†

95% confidence interval.
 

Source: Nancy Kaufman et al., unpublished data. Ethnic differences in public attitudes about policy alternatives
 

for limiting youth access to tobacco products: results of a national household survey, 1994.
 

270 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

program teaches students to serve as peer counselors 

who can provide information on smoking prevention 

and cessation to other high school students. However, 

little information is available on the counselors’ success in racial/ethnic communities. 

Some of the largest experimental school-based 

programs that have included children from racial/ 

ethnic minority groups are briefly described in this section. This listing is not exhaustive because previous 

reports have reviewed this type of program (Lynch and 

Bonnie 1994; USDHHS 1994). These interventions represent the variety of school-based approaches used in 

racial/ethnic neighborhoods. 

Project SMART (Self-Management and Resistance 

Training) 

Project SMART is an in-school program designed 

to encourage junior high school students to resist pressure to use cigarettes and other drugs by teaching them 

stress-reduction skills, social-resistance skills, and 

personal decision-making skills. Implemented in 12 

sessions, Project SMART provides the students with 

role-playing opportunities and offers specific techniques for resisting cigarettes, alcohol, marijuana, and 

other drugs. In an assessment of this program, Graham and colleagues (1990) interviewed seventh graders in 16 California schools between 1982 and 1986. 

Approximately 6 percent of the participants were Asian 

American, 20 percent were African American, 31 percent were Hispanic, and 43 percent were white. The 

program materials, dissemination channels, and evaluation procedures were not tailored specifically for any 

of these racial/ethnic groups. Differential effects for 

cigarette smoking on the basis of participants’ gender 

and racial/ethnic minority background were found. 

Overall, seventh-grade girls were more positively affected by the program than were seventh-grade boys, 

and Asian Americans were more likely than other 

racial/ethnic groups to be affected by the intervention. 

Hispanics and whites were marginally affected by the 

program, whereas African Americans did not appear 

to be affected at all. 

Life Skills Training Program 

The Life Skills Training (LST) Program is a 

tobacco-use prevention curriculum that teaches adolescents positive life options and social-resistance skills. 

The program aims to help students enhance their selfesteem, resist tobacco advertising appeals, cope with 

anxiety, and develop verbal and nonverbal communication skills as well as social and assertiveness skills, 

including techniques to resist social pressures to smoke 

(Botvin et al. 1989a, 1992; Dusenbury and Botvin 1992). 

Program lessons focus on (1) tobacco information, (2) 

social skills, (3) personal skills, and (4) self-improvement. 

Each program includes instruction, behavior modeling and rehearsal, and group feedback. The LST curriculum was initially developed for use with white 

youths, but the curriculum was later modified for use 

with Hispanics and African Americans, following consultations with psychologists, educators, reading specialists, and urban adolescents from various racial/ 

ethnic groups. To assess its feasibility, acceptability, 

and effectiveness in an urban African American population, the LST curriculum was tested in a pilot study 

involving 608 African American seventh-graders in 

New Jersey (Botvin et al. 1989a). The study found that 

the curriculum was acceptable to African American 

teachers and students and could be implemented with 

little difficulty in an urban setting. Three months after 

the intervention, investigators found a 56 percent reduction in the proportion of adolescents who reported 

that they had smoked in the previous 30 days. In an 

earlier study, Botvin and colleagues (1989b) found that 

the use of the LST curriculum was feasible and acceptable among Hispanic seventh-graders attending urban 

schools in northern New Jersey and in New York City. 

More recently, researchers studied the LST 

curriculum’s effectiveness among Hispanic students 

in the New York City area and found significant 

changes in knowledge, smoking behavior, and normative expectations concerning peer and adult smoking 

among students in the schools targeted by the intervention, compared with students in control schools 

that did not implement the curriculum (Botvin et al. 

1992). Consistency in the findings varied, however, 

because of implementation difficulties across schools. 

General problems, such as limited resources and stressful conditions in urban schools, may have contributed 

to these difficulties. 

Project SHOUT (Students Helping Others 

Understand Tobacco) 

Project SHOUT was a three-year tobacco-use 

prevention program that began in 1988 and targeted 

San Diego students who were in the seventh grade at 

the beginning of the program (Sallis et al. 1990; Elder 

et al. 1993b). About 51 percent of the students who 

participated in the program for all three years were 

white, and 28 percent were Hispanic. The program 

consisted of lessons and activities, led by college undergraduate students, on such topics as the consequences of tobacco use, refusal and decision-making 

skills, and the antecedents and social consequences of 

tobacco use. Efficacy of the program was measured 

Tobacco Control and Education Efforts 271 
 

Surgeon General's Report 

with preintervention and postintervention questionnaires administered to students at the end of grades 

seven, eight, and nine. In addition, the efficacy of the 

program was tested by using a physiological measurement to detect cigarette smoking and an audiotaped 

skills assessment of the students’ ability to refuse offers of cigarettes (Sallis et al. 1990). Follow-up 

telephone calls and mailings were made during the 

last year of the intervention to reinforce the program. 

The proportion of Project SHOUT students who reported smoking in the previous month increased from 

8.3 percent at the end of the seventh grade to 13.2 percent at the end of the ninth grade. In comparison, 9.2 

percent of control students reported smoking in the 

previous month at the end of the seventh grade, and 

19.8 percent reported smoking in the previous month 

at the end of the ninth grade. When researchers used 

logistic regressions to analyze the prevalence of cigarette smoking during the previous month among ninth 

graders, comparing control and experimental groups, 

the results were statistically significant for whites but 

not for Hispanics (Elder et al. 1993b). When researchers considered cigarette smoking during the previous 

week, they found statistically significant results for 

both Hispanic and white respondents. When offered 

a cigarette in a mock situation, students who received 

refusal skills training provided more appropriate responses than those who did not receive the training 

(Sallis et al. 1990). 

Southwestern Cardiovascular Curriculum Project 

and Pathways to Health 

In 1990, the University of New Mexico began a 

series of projects designed to educate Navajo and 

Pueblo youths about cardiovascular health and the 

prevention of cancer. The Southwestern Cardiovascular Curriculum Project, founded by the National 

Heart, Lung, and Blood Institute, provides fifth-grade 

Navajo and Pueblo youths with information on the 

health effects of tobacco use and helps them develop 

skills to resist social pressures (Davis et al. 1995b). An 

evaluation of the program showed that among students who had tried cigarette smoking at baseline, boys 

who were randomly assigned to the program reported 

decreasing their cigarette smoking more than those not 

participating. 

The Pathways to Health program, developed 

with funding from the NCI, involves fifth and seventh 

graders in nine Navajo and Pueblo schools in rural 

northwest New Mexico (Davis et al. 1995a). This 

16-lesson curriculum is designed to improve Navajo 

and Pueblo Indian children’s decision-making 

abilities regarding health (Cunningham-Sabo and 

Davis 1993). The curriculum includes skill acquisition, 

self-discovery, and class discussion, and it blends traditions of Navajo and Pueblo Indians. Overall, the 

project promotes a diet low in fat and high in fiber, 

fruits, and vegetables, and it teaches students to avoid 

both cigarettes and smokeless tobacco (CunninghamSabo and Davis 1993). Results of the baseline testing 

showed that a large proportion of fifth (30.6 percent) 

and seventh (60.4 percent) graders had tried cigarette 

smoking (Davis et al. 1995a). Although 64.5 percent 

of fifth-grade girls and 41.0 percent of fifth-grade boys 

expressed intentions to never smoke, by the time they 

became seventh graders, only 37.8 percent of seventhgrade girls and 24.5 percent of seventh-grade boys reported intentions to never smoke. Tribal differences 

were also noted. Pueblo students reported higher use 

of cigarettes, and Navajos reported higher use of 

chewing tobacco and snuff. 

Other Primary Prevention and 

Intervention Efforts 

Other primary prevention and intervention programs have been relatively small in scale and have 

directly targeted members of a given racial/ethnic 

minority group. For example, Cella and colleagues 

(1992) recently designed a smoking-prevention curriculum for 309 mostly African American (57 percent) 

and Hispanic (19 percent) sixth- and seventh-graders 

from the Chicago area. The program included two 

assemblies that were attended by all students. The 

first assembly featured a rap video developed by African American adolescents in Richmond, California, 

and a talk by an African American oncologist on the 

health risks of smoking and social pressures to smoke. 

The second assembly featured a rap contest in which 

students performed original rap songs they had written to convey messages about smoking prevention. 

After the first assembly, students who participated in 

small follow-up groups were found to have more negative attitudes toward smoking, compared with students attending the larger assembly. There were no 

differences in attitudes towards smoking between students who decided to participate in the rap contest and 

those who did not. No data were collected on the 

intervention’s possible effects on rates of smoking initiation or continuation. 

Another small-scale tobacco-use prevention 

effort targeted American Indian children from two 

Washington State reservations (Schinke et al. 1988). 

American Indian children participating in the project, 

who were an average of 11.8 years of age, received 

272 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

training in communication, coping, and cognitive 

decision-making skills from a bicultural perspective. 

At a six-month follow-up, children who participated 

in the program were less likely than children in a control group to report that they had smoked tobacco or 

used smokeless tobacco within the previous 14 days. 

A prevention project now under way in American Indian communities in the northeastern United 

States involves 260 American Indian adolescents in an 

after-school cancer education program (Schinke et al. 

1996). The intervention merges tribal culture with an 

educational approach that uses storytellers and role 

models from the community. The curriculum provides 

students with information on problem-solving skills, 

the historical use of tobacco among northeastern Indian tribes, and health and media literacy to show how 

lifestyle habits are heavily promoted through mass 

media. Problem-solving skills, the historical use of 

tobacco among northeastern Indian tribes, and American Indians’ heritage are celebrated through such 

activities as making story bags (bags containing mementos that are reminders of the story) and dance 

sticks. A preliminary evaluation of the project has 

shown that American Indian youths who received the 

tobacco use curricula or the combined tobacco use and 

dietary curricula had more knowledge and understanding of the health problems associated with tobacco use. In addition, students receiving the tobacco 

use or the combined curricula were more aware of the 

role of peers, relatives, and the media in shaping 

people’s dietary and tobacco preferences (Schinke et 

al. 1996). In another program, involving American 

Indian children in the northwestern states, Moncher 

and Schinke (1994) have shown that a culturally 

appropriate skills-learning curriculum can be more 

effective when combined with community involvement in the prevention of tobacco use. 

Schinke and colleagues (1994) recently developed 

a program targeting American Indian youths. Based 

on a legend of the Seneca Nation, the program features an interactive software package entitled Boy and 

Woman Bear, which provides culturally appropriate 

information on how young people can reduce their risk 

of cancer via good nutrition and only very limited, 

nonhabitual use of tobacco. The effectiveness of the 

software was measured with 368 American Indian 

youths, aged 10–14 years, in the southeastern United 

States. As expected, the youths who participated 

in the program were more knowledgeable about 

nutrition and tobacco-related facts than were nonparticipants. Further research by these authors (Schinke 

et al. 1996) has shown the strong effects of multitopic 

interventions with American Indians. 

The Alaska Area Native Health Service of the 

Public Health Service conducted a pilot study of a 

school-based intervention targeting 240 Alaska Native 

children in grades two through six in three Eskimo 

villages (Bruerd et al. 1994). The curriculum, a modification of previously developed programs, was delivered in 12–15 lessons and involved the children’s 

families in some of the activities. The evaluation of 

the program showed a decrease in cigarette smoking 

and in the use of snuff in two of the three villages that 

participated. The program was most effective when 

teachers attended training sessions and fully implemented the curriculum. Another program sponsored 

by the Alaska Area Native Health Service, the Great 

Alaska Spit-Out, educates Alaska Native schoolchildren and adults about the health risks associated with 

smokeless tobacco use (Burhansstipanov and Dresser 

1993). Schoolchildren in rural Alaska communities 

prepare essays and public service announcements regarding the health problems associated with tobacco 

use. All children who submit entries receive certificates. Monetary awards are given for the best essays, 

and trips to Washington, D.C., are awarded to the firstplace winners. 

As an adjunct to tobacco control curricula, cigarette smoking bans on school grounds have been imposed in some states (recent federal legislation, Public 

Law 103–227, Part C, mandates that schools receiving 

federal monies be tobacco-free). Although some states 

and school districts have prohibited students from 

using tobacco on school campuses, they have excluded 

administrators, teachers, and volunteers from such 

policies, most likely because some adults are resistant 

to tobacco-use bans. Data from the 1992 California 

Tobacco Survey showed that a relatively low proportion of California adults and youths favored banning 

cigarette smoking on school grounds (Pierce et al. 1994a). 

Whites (22.3 percent) were the most willing to ban 

smoking on school grounds, followed by Asian Americans and Pacific Islanders (16.5 percent), African Americans (16.3 percent), and Hispanics (11.1 percent). 

Mass Media Efforts to Prevent Tobacco Use 

A few programs have developed mass media 

materials to prevent tobacco use among children in 

racial/ethnic minority groups. Most of these programs 

use television commercials and videotapes to present 

prevention messages in a targeted fashion. Stop Before 

You Drop, a 10-minute videotape developed by African American adolescents in Richmond, California 

(American Lung Association [ALA] 1990b), presents a 

Tobacco Control and Education Efforts 273 
 

Surgeon General's Report 

preventive message through stories, rap songs, and 

dancing; this videotape is available through local affiliates of the ALA. It’s No Joke, Don’t Smoke! is a 

30-minute videotape that openly discusses tobacco use 

among children and young adolescents in racial/ 

ethnic minority groups (California Department of 

Health Services, Tobacco Control Section 1993). Other 

mass media prevention approaches include theatrical 

works presented at school assemblies or during community events and the distribution of newsletters and 

newspapers in schools and through other community 

outlets. 

No data on the effectiveness of these and similar 

prevention efforts are available because these activities are relatively new. Although these efforts incorporate the musical preferences of young adolescents 

(for example, as reflected in programming on MTV 

[Music Television]) and feature actors from the racial/ 

ethnic groups being targeted, rarely do the messages 

properly reflect the attitudes, expectations, and normative beliefs of the targeted children. Instead, most 

of these efforts have allowed untrained scriptwriters 

(often children from the targeted group) to produce 

the text. Although this approach benefits from the use 

of words and expressions that are familiar to the targeted children, it fails to incorporate attitudinal change 

strategies and the results of studies identifying predictors of tobacco use (see Chapter 4). 

Also problematic is the lack of information regarding the best media outlet to use in presenting 

smoking-prevention campaigns to youths in various 

racial/ethnic groups, both in terms of frequency of use 

and in their perceived credibility and motivating 

power. In a study of 349 Chicago youths aged 5–15 

Smoking Cessation Programs 

years, Blosser (1988) found differences across racial/ 

ethnic groups in the quantity, frequency, and access to 

various media. For example, 70.8 percent of African 

Americans in the sample reported watching television 

during dinner, compared with 64.6 percent of Puerto 

Ricans, 58.8 percent of whites, and 58.1 percent of 

Mexican Americans. Racial/ethnic group differences 

were also found for access to various media; large proportions of youths reported that they owned a television set (100 percent of whites, 99.0 percent of African 

Americans, and 97.7 percent of Hispanics), but varying proportions of youths reported that they owned 

an audiocassette player (80.0 percent of whites, 77.1 

percent of Mexican Americans, 62.5 percent of African 

Americans, and 54.8 percent of Puerto Ricans). In a 

recent survey of Los Angeles children 8–12 years of 

age, Raymond J. Gamba (unpublished data) found that 

children perceived some media channels to be more 

believable than others when information on tobacco 

was presented. Overall, respondents perceived talks 

at school (63 percent), books and pamphlets (54 

percent), television programs (54 percent), radio commercials (52 percent), and television commercials (52 

percent) to be highly credible in presenting information about tobacco use. Students’ perceptions varied 

by ethnic group. For example, a large proportion of 

African Americans perceived books and pamphlets to 

be the most credible channels of information, followed 

by billboards, posters, newspapers, and television programs and commercials. A large proportion of Asian 

Americans and Hispanics, however, perceived talks 

at school to be highly credible, followed by television 

and radio commercials. 

Most structured smoking cessation programs 

directed at members of racial/ethnic minority groups 

have emphasized a self-help approach with some supportive adjuncts, such as motivational messages in the 

mass media or the use of peers or relatives as motivators and supporters (Stotts et al. 1991). This emphasis 

on self-help may be a direct result of the fact that most 

smokers quit on their own (Fiore et al. 1990). Some 

programs have successfully used materials developed 

for whites, with little or no adaptation for the racial/ 

ethnic group being targeted. Though there is currently 

little research on the development of culturally appropriate smoking cessation programs, culture-specific 

tailoring or the development of culturally appropriate programs may be necessary in order to enhance 

effectiveness. At a minimum, programs must be communicated in a language understood by the target audience (Fiore et al. 1996). 

274 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

In this section, six major intervention approaches 

are described: (1) self-help programs, (2) group programs, (3) community interventions, (4) programs in 

health care settings, (5) employer-sponsored programs, 

and (6) nontraditional provider interventions. When 

available, the results of outcome evaluations of the 

projects or strategies are mentioned. Because most of 

these projects are relatively new, there is a paucity of 

research measuring the effectiveness of the various 

strategies and programs. These descriptions provide 

an overview of the different approaches that have been 

used; the list is not complete and does not necessarily 

represent the most effective interventions or model 

programs. Future research efforts should consider the 

components of culturally appropriate interventions 

(Marín 1993) and conduct proper process and outcome 

evaluations to provide a better understanding of the 

effectiveness of various targeted intervention 

approaches. 

Self-Help Approaches 

In the United States, most people who quit smoking do so without the help of formal programs, therapy, 

or nicotine replacement (Pierce et al. 1989; Fiore et al. 

1990; Stotts et al. 1991). Members of racial/ethnic minority groups, however, generally seem to have less 

success with self-help approaches than whites. For 

example, recent analyses of the 1986 Adult Use of 

Tobacco Survey showed that African Americans 

tended to be less successful at quitting smoking than 

whites (Fiore et al. 1990). 

A number of self-help cessation materials and 

programs have been developed for members of racial/ 

ethnic groups who want to quit on their own. Some 

of these materials and programs are adaptations of 

materials and programs previously developed for 

whites, usually by federal agencies such as the NCI or 

voluntary associations such as the ALA. Other programs and materials have been developed specifically 

for members of these racial/ethnic groups; however, 

only a few studies report on the success of these programs in helping members of racial/ethnic groups quit 

smoking. 

Smokers from racial/ethnic minority groups tend 

to favor relying on willpower alone to quit smoking. 

In a 12-state survey of 1,163 low- to middle-income 

African American insurance policyholders aged 21–60 

years, Orleans and colleagues (1989) found that 89.3 

percent of those who were former smokers reported 

relying primarily on willpower to quit smoking and 21.7 

percent reported relying primarily on prayer and meditation. These former smokers also reported seldom 

using cessation aids of any type, including smoking cessation groups (0.4 percent) or books and guides (3.2 percent). Likewise, Hispanic smokers surveyed in San 

Francisco perceived willpower as the most effective 

technique for quitting smoking (Marín et al. 1990a). 

Rompa Con el Vicio: Una Guía Para Dejar de 

Fumar (Break the Habit: A Guide to Stop Smoking) 

The first self-help manual designed specifically 

for a U.S. racial/ethnic group was developed in 1988 

in San Francisco as part of the Programa Latino Para 

Dejar de Fumar (Hispanic Program to Quit Smoking). 

The manual was distributed by the NCI under the 

name Guía Para Dejar de Fumar (Sabogal et al. 1988) 

and was based on a significant number of studies that 

identified group-specific attitudes, norms, expectancies, and values related to cigarette smoking and smoking cessation among Hispanics and whites (Marín et 

al. 1990a,b). Initial versions of the manual (hereafter 

referred to as the Guía) were thoroughly pretested to 

identify optimal formats, designs, photographs, typefaces, and publication format and size. In 1991, a revised version, El Fumar, Un Juego Peligroso: Guía Para 

Dejar de Fumar, was published and distributed in California with funding from Proposition 99 tax revenues 

earmarked for tobacco control activities (Programa 

Latino Para Dejar de Fumar de San Francisco 1992). 

In 1993, the NCI published and distributed nationally 

the third edition, Rompa Con el Vicio: Una Guía Para 

Dejar de Fumar (Programa Latino Para Dejar de Fumar 

de San Francisco 1993). 

The Guía is a 24-page, 81

/2 -by-11-inch, full-color 

booklet printed on glossy paper and featuring 

photographs of numerous Hispanic individuals demonstrating various cessation techniques as well as their 

testimonials about quitting smoking. All text is in 

broadcast Spanish—that is, conversational Spanish 

used by television broadcasters and easily understood 

by all Spanish-speaking Hispanics. The first section 

of the Guía describes the short- and long-term effects 

of cigarette smoking, including health problems among 

smokers and their relatives and the negative social effects, such as bad breath and bad-smelling clothes. The 

second section presents possible methods a smoker can 

follow to quit, particularly approaches that Hispanic 

smokers perceive to be effective (Marín et al. 1990a). 

In addition, this section offers suggestions and verbal 

scripts for dealing with social pressures to smoke as 

well as for dealing with stress or depression. The third 

section presents strategies to follow after a relapse. The 

final section lists ways relatives and friends can motivate and support smokers who are trying to quit. 

Tobacco Control and Education Efforts 275 
 

Surgeon General's Report 

The effectiveness of the first edition of the Guía 

was evaluated in a study of 431 Hispanic smokers who 

volunteered to participate after they picked up the 

manual at community stores or clinics in San Francisco 

(Pérez-Stable et al. 1991). More than 21 percent of the 

participants reported that they had quit smoking 2.5 

months after reading the Guía; however, this percentage declined to 18.6 percent after more than 8 months 

and to 13.7 percent after 14 months. 

Pathways to Freedom 

Pathways to Freedom: Winning the Fight Against 

Tobacco is a self-help manual targeting African Americans (Robinson et al. 1992). The manual and a companion 12-minute videotape were developed by the 

Fox Chase Cancer Center in Philadelphia with funding from the NCI and assistance from a number of 

African American churches and other community 

groups. The manual was designed to emphasize quitting and community mobilization. In the early stages 

of the manual’s development, focus group participants 

and community leaders who were interviewed suggested that the manual should include graphics depicting African Americans representing everyday 

people of all ages, should provide strong visuals illustrating the health consequences of cigarette smoking, 

and should target smokers and nonsmokers. Persons 

in the interviews and focus groups also suggested that 

the manual and videotape include information on targeted advertising and that they identify the tobacco 

industry as the enemy. 

The resulting manual, Pathways to Freedom, is a 

36-page, 8 1/2 -by-11-inch, glossy publication with numerous color photographs and line drawings. The first 

part of the manual discusses the characteristics of cigarette smoking among African Americans; the tobacco 

industry’s influence on the community through advertising and promotional campaigns; and the effects of 

stressors, such as unemployment and racism, that promote cigarette smoking behavior. The second part provides instructions on how to quit smoking and help 

smokers quit, and the third part shows how communities can combat tobacco dependence by working 

together. The manual addresses the tobacco-related 

concerns of African American smokers as well as 

other community members. It covers such topics as 

cigarette-smoking patterns among African Americans, 

culturally appropriate strategies to quit smoking, 

messages that nonsmoking friends and relatives can 

use to help smokers quit, and the role of prayer and 

faith in helping people quit and avoid a relapse. The 

manual was distributed nationally as part of the 

Legends campaign carried out in 1993 and 1994 by CDC 

and the National Medical Association (NMA). As part 

of an American Cancer Society Pathways to Freedom 

Community Demonstration Project launched in 1992, 

285 African American smokers who received the 

manual agreed to participate in postintervention evaluations. About 71 percent of respondents read some or 

all of the guide, and 56 percent of those who did reported trying to quit smoking. Approximately 75 percent of those who tried to quit reported being able to 

stay off cigarettes for at least 24 hours. Most respondents reported that the manual was easy to read, that 

the graphics were appropriate, and that it was useful 

overall (C. Tracy Orleans et al., unpublished data). For 

more information on the evaluation project, see the 

discussion later in this chapter under “Community 

Approaches.” 

Làm Thê’ Nào Dê Bo Hút Thuô’c? (How to Quit  ̧  ̧

Smoking) 

Làm Thê’ Nào Dê Bo Hút Thuô’c?  ̧  ̧ is a self-help, 

smoking cessation manual developed in 1990 to help 

Vietnamese smokers quit (Vietnamese Community 

Health Promotion Project 1990). The 30-page, 81/2 -by11-inch manual was developed as part of the Vietnamese Community Health Promotion Project based at the 

University of California, San Francisco. The manual’s 

format is similar to that of the Guía and covers topics 

such as reasons for quitting smoking, the health effects of cigarette smoking, approaches to quitting, dietary concerns while quitting, and suggestions for 

avoiding and coping with relapse. The manual, available through the California Department of Health Services’ Tobacco Control Section, features full-color 

photographs. 

It’s Your Life—It’s Our Future 

It’s Your Life—It’s Our Future is a 28-page smoking 

cessation, self-help manual targeting American Indian 

adults (American Indian Cancer Control Project 1991). 

The manual was developed by the American Indian 

Cancer Control Project in Berkeley, California, with 

NCI funding. The two-color, spiral-bound manual is 

printed on high-quality paper. The first section of the 

manual provides motivational information on quitting 

smoking, including the negative effects of smoking and 

the positive effects of quitting. The second section 

presents techniques to help smokers reduce the number of cigarettes smoked per day and offers suggestions on what to do before and after quitting and how 

to deal with withdrawal symptoms. The last section 

276 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

of the manual provides suggestions on how to stay 

free of cigarettes, such as how to deal with pressure to 

smoke from family and friends, how to control stress, 

and how not to gain weight. The contents of the 

manual, the presentation of the materials, and the 

approach to quitting that is promoted in this manual 

reflect the values of American Indians and their emphasis on the family and the community. The manual 

is formatted for easy reading; for example, the sections 

have bulleted headings, and the text is printed in large 

type. American Indian artwork and pictures are featured throughout the manual. A 16-minute videotape 

was produced to further motivate smokers to quit and 

to remain smoke-free (American Indian Cancer Control Project 1991). 

Victory Over Smoking—A Guide to Smoking 

Cessation for You and Your Family 

The Chinese Community Smoke-Free Project of 

the Chinese Hospital in San Francisco produced a 46­

page smoking cessation manual entitled Victory Over 

Smoking (Chinese Community Smoke-Free Project 

1992) with funding from California’s Proposition 99 

tobacco tax initiative. The 8 1

/2 -by-11-inch manual is 

printed on glossy paper and has black-and-white 

photographs of Chinese Americans and line drawings. 

The manual is written in Chinese, and it describes a 

number of suggested attitudes and behaviors that are 

specific to and consonant with Chinese culture. For 

example, “living long enough to see one’s grandchildren grow” is presented as a possible benefit to 

quitting, and martial arts is suggested as a possible 

alternative to smoking. The five-part manual was pretested with focus groups of San Francisco’s Chinese 

American residents. The first section describes cigarette smoking among Chinese Americans, and the 

second section describes common health effects of 

cigarette smoking. The third section presents steps 

smokers can take as they prepare to quit. The next 

section describes alternatives to smoking as well as 

techniques and activities for remaining smoke-free. 

The final section provides suggestions on how to maintain abstinence, such as through physical exercise, deep 

breathing exercises, and diet. 

Smoking: Facts and Quitting Tips Series 

In 1992, the NCI produced two small brochures, 

Smoking: Facts and Quitting Tips for Black Americans 

(NCI 1992b) and Smoking: Facts and Quitting Tips for 

Hispanics (NCI 1992a). Despite the difference in titles, 

the brochures are basically identical in content. The 

major difference between the brochures is that the one 

targeting Hispanics includes text in both English and 

Spanish. No information is yet available on their 

effectiveness. 

Hot Lines 

Hot lines for smokers who want to quit provide 

callers with short-term counseling over the telephone 

and self-help materials via the mail. Probably the most 

prominent of these hot lines is the Cancer Information 

Service (CIS), funded by the NCI, which provides services and information to persons wishing to quit smoking. The CIS provides services in English as well as in 

Spanish in states with high concentrations of Hispanics. The CIS also provides Spanish-speaking counselors and callers with Spanish-language materials, 

including copies of the Guía. 

Some states have implemented their own smoking cessation hot lines. For example, California recently funded a hot line to help smokers quit by 

providing short-term telephone counseling. Between 

August 1992 and December 1993, the California hot 

line received calls from more than 18,000 smokers 

(Pierce et al. 1994b). Most of these calls came from 

whites (56.8 percent), followed by Hispanics (20.6 percent), African Americans (16.1 percent), and Asian 

Americans (2.4 percent). These figures show that the 

proportion of African American and Hispanic smokers reached by the California hot line was similar to or 

higher than the proportion of African American smokers (7.0 percent) and Hispanic smokers (18.6 percent) 

in the state, whereas the proportion of Asian American smokers reached by the hot line was lower than 

the proportion of Asian American smokers in California (5.0 percent). 

Group Approaches 

In general, smoking cessation programs that are 

group-based have had difficulty attracting participants, 

and attrition rates are often high. The scant data available for racial/ethnic groups indicate that similar difficulties may exist to an even greater extent. For example, 

Hispanics and Asian Americans rarely participate in 

smoking cessation groups (Pérez-Stable et al. 1993). The 

same is true for African Americans (Hymowitz et al. 

1996). The possible reasons are varied (Glynn 1989; 

Stotts et al. 1991; Lichtenstein and Glasgow 1992): 

•	 They may have difficulty accessing primary health 

care facilities that offer smoking cessation services 

(because of eligibility criteria or physical distance). 

Tobacco Control and Education Efforts 277 
 

Surgeon General's Report 

•	 They may be unable to afford the high cost of some 

group interventions. 

•	 They may perceive such efforts to be inconvenient 

(e.g., requiring transportation and child care) and 

time consuming. 

•	 They may prefer to deal with personal problems 

alone or in the family rather than to seek professional or other help outside of the home. 

•	 They may lack access to linguistically appropriate 

services. 

•	 They may distrust researchers and health care providers who are not members of their racial/ethnic 

groups or who are unaware of their culture and 

behavioral expectations and traditions. 

•	 If they have physically demanding jobs or heavy 

caregiving responsibilities, they may be too exhausted to attend program meetings. 

The difficulty in obtaining enough individuals 

to participate in smoking cessation groups or even to 

continue their participation after a few initial sessions 

has been a problem for many ethnic smoking cessation programs, including those targeting Hispanics in 

San Francisco, California (Pérez-Stable et al. 1993) and 

Queens, New York (Nevid and Javier 1992), African 

Americans in Atlanta, Georgia (Ahluwalia and 

McNagny 1993), and Chinese restaurant workers in 

Boston, Massachusetts (Betty Lee Hawks, personal 

communication, 1993). As a result, many programs 

have stopped using cessation groups as a possible intervention strategy and as a way to deliver information personally. 

As an alternative to group approaches, intervenors in San Francisco began offering personal consultation over the telephone and face-to-face (Pérez-Stable 

et al. 1993). Trained individuals provide information 

and support to smokers who want more information 

than is provided in a self-help manual. This approach 

(labeled consultas, or personal consultations), although 

demanding in terms of time and personnel, is considered culturally appropriate among Hispanics, who traditionally value personal attention. This alternative also 

allows telephone advisors to tailor the information to 

each person’s needs. Another alternative program, 

which provides individual counseling to Southeast 

Asian smokers in their homes rather than in clinics, has 

been well received in Long Beach, California (Mary 

Anne Foo, personal communication, 1994). 

Community Approaches 

Most community smoking cessation programs 

targeting members of racial/ethnic groups have been 

conducted in fairly large urban communities and have 

used self-help materials together with mass media and 

outreach workers. In a recent overview of communitywide programs targeting cardiovascular disease, 

Winkleby (1994) noted the need to conduct focused 

studies with populations that have not been reached 

successfully in the past with large-scale projects, as is 

the case with members of the four racial/ethnic 

minority groups considered in this report. 

Because so many racial/ethnic groups place a 

high value on the family and on the authority of older 

relatives (Sabogal et al. 1987), some community programs have employed family-centered interventions, 

working under the assumption that a smoker’s children and other relatives can effectively intervene and 

that parents can be a child’s best source of information regarding smoking-prevention programs. In 

Boston, the South Cove Community Health Center 

involved more than 350 Chinese elementary school 

children in a poster contest to depict the hazards of 

tobacco. Many of these posters depicted the father 

smoking at home and motivated children to discuss 

cigarette smoking in their homes (Esther Lee, personal 

communication, 1993). In a Vietnamese Saturday language school program in Sacramento, California, 

youths have been mobilized to carry antismoking 

messages to their families and to encourage them to 

avoid using tobacco (Debra Oto-Kent, personal communication, 1993). In another project, Asian American 

and Pacific Islander children were asked to compete in 

a “letter to my parents” writing contest, asking them 

not to smoke (Irene Linayao-Putman, personal communication, 1993). Anecdotal information about this and 

similar programs indicates that the children enjoy these 

activities and that their parents are seldom discomforted 

by the letters, particularly when they perceive the programs to be sanctioned by the school system. Nevertheless, the usefulness of such an approach may be 

limited in families that maintain strict patriarchal or matriarchal structures in which children’s interventions 

may be perceived as a lack of respect toward adults or 

as a challenge to the parents’ authority. 

As mentioned previously, large-scale community 

projects generally have used multiple strategies and 

channels to disseminate smoking cessation information and to motivate smokers to quit. A sample of programs targeting members of the four racial/ethnic 

groups is presented below. This listing represents the 

278 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

variety of community approaches developed to help 

racial/ethnic smokers quit but should not necessarily 

be perceived as a list of model programs. 

Stanford Five-City Multifactor Risk 

Reduction Project 

Researchers at Stanford University developed the 

Stanford Five-City Multifactor Risk Reduction Project 

to examine cardiovascular disease and related risk factors over a nine-year period in five small communities in northern California. The project was based on 

behavior-change models and social-learning theory 

(Farquhar et al. 1985, 1990) and used television, massdistributed print media, direct mailings, contests, correspondence courses, and school-based programs for 

youths. In the communities with very high concentrations of Hispanics, Spanish-language radio and 

newspaper columns were chosen as the primary methods of disseminating information. The decline of 

smoking rates was 13 percent greater in the treatment 

cities than in the control cities (Farquhar et al. 1990). 

Although researchers observed no differences in the 

proportion of experimental or control respondents who 

reported ever receiving advice from physicians on 

quitting smoking, whites (51.1 percent) were much 

more likely to report having received this advice than 

Hispanics (32.6 percent) (Frank et al. 1991). 

Researchers found that the project was fairly successful in promoting the use of self-help smoking cessation materials among whites. A greater proportion 

of smokers in the experimental communities (22.1 percent) than in the control communities (15.0 percent) 

reported using smoking cessation materials in the 12 

months before the interview (Jackson et al. 1991). In 

the experimental communities, Hispanics and whites 

did not differ in their reported use of materials to reduce cardiovascular risk. When asked about their use 

of tobacco control materials, 31.0 percent of Hispanic 

women and no Hispanic men reported using smoking cessation print materials during the previous 12 

months, compared with 21.3 percent of white women 

and 13.7 percent of white men. 

The project was less effective in promoting smoking cessation programs; no Hispanic smokers reported 

using such programs, compared with 6.3 percent of 

white smokers. More recent analyses of and comment 

on risk-reduction data from this and other communitybased interventions suggest that such interventions can 

achieve more positive results by being coupled with 

policy initiatives, developing more focused studies, 

and broadening evaluation concepts (Winkleby et al. 

1992; Fortmann et al. 1993; Winkleby 1994). 

Programa Latino Para Dejar de Fumar (Hispanic 

Program to Quit Smoking) 

The Programa Latino Para Dejar de Fumar was a 

community-based, culturally appropriate intervention 

designed specifically for Hispanic smokers in San Francisco (Pérez-Stable et al. 1993; Marín and Pérez-Stable 

1995). Funded by the NCI for 1985–1995, the program 

was operated jointly by the University of California, 

San Francisco, and the University of San Francisco. To 

motivate Hispanic smokers to quit and to inform them 

of strategies to stop smoking, the program used mass 

media (primarily radio and television public service 

announcements), outreach efforts, and distribution of 

the Guía. Program planners developed the various 

versions of the Guía, implemented the consultas approach to deal with individual needs for counseling, 

and used a periodic raffle to reward individuals who 

quit smoking within a given period of time (PérezStable et al. 1993). Intervention messages were based 

on research that identified the attitudes, norms, expectancies, and values of Hispanic smokers (Marín et al. 

1990a,b). The strategies incorporate significant cultural 

values such as familialism (the normative and behavioral influence of relatives) (Sabogal et al. 1987) and 

simpatía (a social mandate for positive social relationships) (Triandis et al. 1984). For example, a key message of the program was that smokers should quit to 

protect the health of their children and to avoid setting a bad example for children. To incorporate 

simpatía into the program, planners developed intervention materials that emphasized the positive aspects 

of quitting and avoid confrontational approaches. This 

latter approach was similar to that used in materials 

developed for American Indians (American Indian 

Cancer Control Project 1991). 

The Programa Latino Para Dejar de Fumar has 

been evaluated through a number of cross-sectional 

and longitudinal surveys as well as through smaller 

scale studies that have examined the effectiveness of 

specific strategies (Marín et al. 1990c, 1994; Pérez-Stable 

et al. 1993; Marín and Pérez-Stable 1995). The program 

has significantly increased Hispanics’ knowledge 

about the dangers of smoking, awareness of the program, and participation in the program. Most important, the program has decreased the prevalence of 

smoking among Hispanics in San Francisco (Marín and 

Pérez-Stable 1995). These changes have been observed 

primarily among the less acculturated Hispanic smokers who make up the targeted group. For example, 

during the first year of the program, 24.9 percent of 

the less acculturated Hispanics in San Francisco reported awareness of the program; two years later, that 

Tobacco Control and Education Efforts 279 
 

Surgeon General's Report 

proportion had increased to 48.5 percent (Marín et al. 

1990b; Marín and Pérez-Stable 1995). During the first 

year in which the Guía was available, 23 percent of the 

less acculturated Hispanic women and 12 percent of 

the less acculturated Hispanic men in San Francisco 

reported having a copy. One year later, the proportion of the less acculturated Hispanics who reported 

having a copy of the Guía had increased to 37.7 percent of the women and 34.1 percent of the men. 

Sí Puedo (Yes, I Can) 

Sí Puedo was an eight-week smoking cessation 

program designed specifically for Hispanic smokers 

in a largely Hispanic area of Queens, New York. The 

program used the Guía and other print materials, 

weekly bilingual group meetings, regular telephone 

calls to offer support to participants, and videotaped 

vignettes in which Hispanic actors conveyed smoking cessation messages. Persons were recruited 

through mass media advertising, direct mailings to 

Hispanic physicians and clergy, and fliers posted 

throughout the community. Most participants were 

from South America (57 percent); the rest were from 

the Caribbean (25.4 percent) or Central America 

(9 percent). Some people participated in all aspects of 

the program, whereas others used only the self-help 

materials. Preliminary figures show that 55.6 percent 

of the participants who took part in all components of 

the Sí Puedo smoking cessation program stopped 

smoking by the end of the program (Nevid and Javier 

1992). In comparison, 21.7 percent of those who used 

only the self-help materials abstained from smoking. 

Pathways to Freedom Community 

Demonstration Project 

The American Cancer Society (ACS) used the 

Pathways to Freedom manual and videotape as part of a 

demonstration project to lower the prevalence of cigarette smoking among African Americans (Robinson et 

al. 1992; Robinson and Sutton, in press). During the 

first phase (1992–1993), the ACS provided funds to 

eight of its local units in Long Beach and central Los 

Angeles, California; Philadelphia, Pennsylvania; Delaware; the District of Columbia; Georgia; Kansas; and 

Texas. The ACS units developed programs to recruit 

African American smokers to quit smoking using the 

Pathways to Freedom materials and to expand the ACS’s 

outreach into African American communities. Many 

of them planned their projects to coincide with the 

Great American Smokeout (GAS). 

In the second phase of the project (1993–1994), 

the ACS provided funding to seven more local units 

in Contra Costa and San Diego Counties, California; 

Maryland; Nebraska; Chattanooga and Memphis, Tennessee; and Utah. Cessation activities expanded to 

include efforts to mobilize African American communities and to identify more individuals and groups 

willing to become tobacco control advocates. 

The process evaluation of the first phase showed 

that the program was easier to implement in communities with a previous history of community-based 

outreach efforts (Robert G. Robinson et al., unpublished data). Dissemination of the self-help manual 

was most difficult in multiethnic communities and 

areas of a city. Most ACS agencies used a variety of 

distribution channels, including churches, health care 

organizations, and recreation centers. The program 

helped the ACS to approach African Americans and 

to gain support from African American volunteers. 

Even though the project emphasized self-help 

approaches, several ACS units incorporated Pathways 

to Freedom materials into smoking cessation groups 

conducted in African American communities. 

The outcome evaluation of the first phase consisted of telephone interviews with 763 smokers who 

returned a screening postcard that was attached to each 

Pathways to Freedom manual. Respondents reported a 

favorable impression of the manual and a 10 percent 

quit rate at 30 days. In addition, smokers who viewed 

the Pathways to Freedom videotape were significantly 

more likely than others to accept and use the self-help 

materials as well as to move from precontemplation 

to contemplation in the process of changes involved 

in smoking cessation. 

Quit Today! 

A two-part study funded by the NCI will evaluate the effectiveness of the Pathways to Freedom manual 

and videotape when incorporated into a communitybased campaign targeting adult African American 

smokers. In the first phase of the project, the 

Pathways to Freedom videotape will be distributed 

communitywide, and paid radio announcements will 

be aired, encouraging smokers to call the CIS for help. 

In the second phase of the project, callers to the CIS 

will be randomly selected to receive either the Pathways to Freedom manual and smoking cessation counseling related to the manual or an NCI manual and 

standard CIS smoking cessation counseling. Results 

of this study should produce important information 

about the effectiveness of targeted self-help smoking 

cessation materials for African Americans combined 

with established services such as the CIS. 

280 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Chicago Lung Association’s Multifaceted Smoking 

Cessation Intervention 

In 1985, Warnecke and colleagues (1991) 

launched a multifaceted smoking cessation intervention on behalf of the Chicago Lung Association. Like 

a number of programs, this intervention used materials originally produced for whites to target members 

of other racial/ethnic minority groups. The program 

used televised messages on techniques for quitting 

smoking and avoiding relapse as well as the ALA selfhelp manual and smoking cessation groups. More than 

325,000 smokers in the targeted population viewed 

televised messages featuring role models who encouraged them to obtain a self-help manual, Freedom from 

Smoking in 20 Days, by mail or at one of three locations—a local hardware store, an HMO, or the Chicago Lung Association. A total of 9,182 smokers (23 

percent of whom were African American) registered 

to participate in the study and were followed for 24 

months. The results showed that African American 

and white smokers responded differently to various 

smoking cessation strategies. For example, African 

Americans were more likely than whites to report seeing the televised messages on a daily basis and were 

more likely to recall the messages. However, African 

Americans were less likely than whites to attend smoking cessation groups. 

As an adjunct to the Chicago Lung Association’s 

program, Jason and colleagues (1988) studied the effects of a television program in the West Garfield Park 

neighborhood of Chicago, where 86 percent of the residents were African American. Before the television 

program aired, individuals who reported smoking 

were randomly assigned to a control group (91 percent were African American) or to an experimental 

group (96 percent were African American). Members 

of the control group viewed the program or read the 

self-help manual at their leisure, whereas members of 

the experimental group received motivational calls 

prompting them to view the television program and 

inviting them to attend smoking cessation meetings 

at a community health center three times during the 

20-day program. Eight percent of the smokers in the 

experimental group reported quitting at the end of the 

program, compared with 1 percent of those in the control group. After four months, 20 percent of the smokers in the experimental group had quit, compared with 

9 percent of those in the control group. 

Chicago Community-Based Interventions for 

Low-Income African Americans 

In conjunction with the smoking cessation 

television program sponsored by the Chicago Lung 

Association, Lacey and colleagues (1991) designed 

community-based interventions for low-income 

African Americans living in four subsidized housing 

projects in Chicago. Residents were trained as lay 

health advisors to deliver smoking cessation messages 

to their neighbors. They made weekly home visits 

during the 20 days in which the television program 

was aired, and they used reminder cards to support 

the positive behaviors outlined in the program. A 

subsample of women in the housing projects watched 

the televised program and participated in six smoking cessation classes, which used a curriculum similar 

to the one presented in the television program. Health 

educators gave the women supplemental materials appropriate for them and tips on sources of social support for smoking cessation. Classes were held in the 

housing projects. Of the 235 residents who preregistered for the smoking cessation intervention, 141 attended at least one class or accepted at least one home 

visit. Of the 56 women who attended at least one class 

session, 11 percent quit smoking. About one-half of 

the 174 residents who registered for the home visitation accepted such a visit, but none quit smoking. 

Focus groups conducted in conjunction with the intervention indicated that residents of the housing 

projects perceived that they were not vulnerable to the 

negative health consequences of smoking, that smoking helped them to cope with stress, and that they had 

few environmental supports for quitting smoking. 

Freedom from Smoking® for You and Your Family 

on TV/Por Su Salud y Su Familia 

Like the Chicago Lung Association’s intervention, the Freedom from Smoking® for You and Your 

Family Project in California featured role models in 

televised pieces and distributed self-help materials. In 

1991, project planners produced special editions of the 

ALA Freedom from Smoking® for You and Your Family 

self-help manual and the Guía and placed them in a 

newspaper insert that was distributed throughout 

seven English-language television markets—Eureka, 

Fresno, Los Angeles, Sacramento, Santa Barbara, San 

Diego, and the San Francisco Bay area—and four 

Spanish-language television markets—Fresno, Los 

Angeles, Sacramento, and the San Francisco Bay area. 

In addition, locally produced television pieces in both 

English and Spanish were shown for seven days as 

part of the daily news. These news pieces included 

interviews with Hispanic and white experts on 

tobacco-use control and with four local residents who 

had volunteered to use the self-help materials to quit 

smoking. The program reached nearly 1.2 million 

Tobacco Control and Education Efforts 281 
 

Surgeon General's Report 

smokers (C. Anderson Johnson et al., unpublished 

data). The newspaper insert was most frequently read 

by white (22 percent), Asian American and Pacific Islander (18 percent), and African American (16 percent) 

smokers; smaller proportions of English-speaking Hispanics (14 percent) and Spanish-speaking Hispanics 

(10 percent) read the insert. The television pieces were 

viewed most frequently by Spanish-speaking Hispanics 

(25 percent), followed by African Americans (14 percent), Asian Americans and Pacific Islanders (9 percent), whites (9 percent), and English-speaking 

Hispanics (9 percent). A year after the intervention, 

3.1 percent of the people who had read the Englishlanguage newspaper insert and had viewed the television piece were former smokers; this was true among 

all racial/ethnic minority groups except Spanishspeaking Hispanics. In comparison, 1.5 percent of the 

people who did not participate in the program were 

former smokers. By itself, neither the English-language 

television piece nor the newspaper insert was effective in promoting smoking cessation. Viewers of the 

Spanish-language television program, which used culturally appropriate materials, were more successful; 9 

percent of viewers were former smokers at 12 months, 

compared with 2 percent of smokers who did not view 

the program. 

A Su Salud (To Your Health) 

A Su Salud was a mass media health promotion 

program conducted from 1985 through 1990 to reduce 

smoking among Mexican Americans residing along the 

U.S.-Mexico border in Eagle Pass and Del Rio, Texas 

(Ramirez and McAlister 1988; Amezcua et al. 1990). 

This mass media campaign used role models, an extensive media campaign, community volunteers, and 

behavioral modeling techniques grounded in the principles of Bandura’s (1977) Social Learning Theory. It 

was modeled after a similar program implemented in 

North Karelia, Finland (McAlister et al. 1982; Puska et 

al. 1987). A Su Salud recruited individuals who wanted 

to quit smoking, organized focus groups to determine 

their needs and levels of awareness about tobacco use, 

and then featured community role models in a series 

of informational programs that were televised on 

local Spanish-language stations. The media messages 

were reinforced through a network of community volunteers who personally contacted the targeted population individually or in small groups. The volunteers 

delivered calendars with community events and stories about the role models. The program also produced 

fotonovelas—pictorial stories, presented in a comic-book 

format, which depicted smoking cessation behaviors. 

The program resulted in a modest but notable increase 

in smoking cessation rates among community members. Out of the 17 percent of smokers who reported 

that they had quit smoking, 8 percent were verified 

(McAlister et al. 1992). 

University of North Carolina/North Carolina 

Mutual Quit for Life Guide 

The Quit for Life program used lay leaders to promote smoking cessation messages. The Quit for Life 

Guide was based on the ALA’s Freedom from Smoking® for You and Your Family Project and targeted policyholders of the predominantly African American 

North Carolina Mutual Life Insurance Company 

(Schoenbach et al. 1988). The program was novel in 

that it was delivered by the company’s life insurance 

sales agents, who discussed the health consequences of 

smoking with their customers and provided social support for quitting and avoiding relapse (Orleans et al. 

1989). The Quit for Life program was moderately effective in promoting smoking cessation among the 

targeted low- to middle-income smokers. Over a 

two-year period, 2,042 smokers enrolled in the program. 

About 14.9 percent of the participants who received 

self-help materials, telephone counseling, and agent 

support quit smoking at 12 months, compared with 14.1 

percent of the participants who received just self-help 

materials and agent support, and 12.3 percent of the 

control subjects, who received agent support only. Verifying these self-reported quit rates was impossible, however, because few respondents agreed to provide saliva 

samples for a cotinine test, which would have provided 

biochemical verification (Schoenbach et al. 1988). 

In an eight-week follow-up study, the Quit for 

Life program targeted the insurance company’s corporate employees in a large urban center. Preliminary 

results regarding policyholders in one sales district and 

lasting eight weeks showed that 8 of the 126 African 

American smokers enrolled in the program (6 percent) 

were nonsmokers six months after enrollment (Sandra 

W. Headen et al., unpublished data). 

Legends 

Beginning in 1993, the NMA and CDC began cosponsoring the Legends campaign. Legends is the only 

national-level, mass media motivational campaign directed at African Americans who want to quit smoking. The campaign consists primarily of public service 

television and radio announcements that use famous 

African American leaders and historic figures, such as 

Martin Luther King, Jr., and Malcolm X, to motivate 

282 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

smokers to quit. Individuals interested in quitting can 

request the Pathways to Freedom cessation guide by calling a toll-free telephone number; the Legends campaign 

generated more than 7,500 calls for the Pathways to Freedom guide within the first 18 months. The NMA has 

supported the campaign at the local level by promoting media and community outreach activities, including billboard advertisements, in 14 NMA-sponsored 

“Healthy People 2000” cities across the country. 

Great American Smokeout 

GAS is an annual ACS-sponsored event that encourages smokers to quit. The results of a 1991 

Gallup poll indicated that smokers of various racial/ 

ethnic minority groups may respond favorably to the 

GAS (CDC 1992). Fewer African Americans and Hispanics than whites reported being aware of the 

Smokeout. However, 25 percent of African Americans 

and Hispanics who were aware of the GAS reported 

participating in the project, and 14 percent of those 

who participated reported that they were not smoking cigarettes one to three days after the GAS (CDC 

1992). The same poll estimated that during the 1991 

GAS, approximately one-third of smokers in the United 

States participated, either by not smoking or by reducing the number of cigarettes they smoked (CDC 1992). 

Lieberman Research Inc. (1993) found that 26 percent 

of smokers from racial/ethnic communities (i.e., 

African Americans, Asian Americans, Hispanics, and 

others) participated in the 1993 GAS, compared with 

only 19 percent of white smokers. In interviews 

conducted 1 to 10 days after the GAS, however, similar 

proportions of racial/ethnic group members (18 percent) and whites (17 percent) reported that they had quit 

or that they were smoking less than before the GAS. 

Suc Khoe La Vang! (Health is Gold!) 

From 1990 to 1992, Suc Khoe La Vang! (Health is 

Gold!), the Vietnamese Community Health Promotion 

Project, conducted media-led smoking reduction campaigns targeting Vietnamese men in San Francisco and 

Alameda Counties and in Santa Clara County, California (McPhee et al. 1993, 1995; Jenkins et al. 1997). 

Both interventions used materials that were produced 

in Vietnamese. The programs included antitobacco 

counteradvertising campaigns that used billboard, 

print, and television advertisements; published articles 

in Vietnamese-language newspapers; a videotape that 

aired on Vietnamese-language television stations; 

health education materials such as brochures, a quit 

kit, posters, bumper stickers, and a calendar; a 

continuing medical education course on smoking 

cessation counseling methods for Vietnamese physicians; and the distribution of printed “no smoking” 

signs and ordinances. Unlike the Santa Clara intervention, the San Francisco campaign was preceded by 

a 15-month pilot antitobacco media program and included a component for students and their families. 

The evaluation of the programs showed that the 

Santa Clara intervention did not influence cigarette 

smoking prevalence or recent quitting status (quitting 

during the prior two years) (McPhee et al. 1995). However, a program effect was observed in the San Francisco trial, such that the odds of being a smoker were 

significantly lower and the odds of quitting recently 

were significantly higher in San Francisco than in a 

comparison community (Jenkins et al. 1997). The authors explained the difference in two ways, the longer 

duration of exposure to the antitobacco campaign in 

San Francisco (39 months) than in Santa Clara (24 

months) and the added school- and family-based 

component of the San Francisco campaign. 

Involvement of Health Care Providers 

A number of successful smoking cessation approaches use health care providers, primarily physicians and dentists, to inform patients about the urgency 

of quitting smoking and to suggest quitting strategies 

(Health and Public Policy Committee 1986; Flay et al. 

1992; Reid et al. 1992; NCI 1994; Fiore et al. 1996). Although this approach may be effective with members 

of the four racial/ethnic minority groups studied in 

this report—particularly those groups that exhibit high 

power distance (i.e., the respect for and deference to 

authority figures such as physicians, teachers, and 

older people) (Hofstede 1980)—a number of structural 

characteristics limit the usefulness of this approach. 

The most important limitation is that a large proportion of members of these racial/ethnic minority groups 

lack access to primary care providers. This problem 

has been widely documented among adult members 

of racial/ethnic groups (Aday et al. 1993) and adolescents (Lieu et al. 1993), such as among African Americans (Hopkins 1993) and Hispanics (Treviño et al. 1991; 

GAO 1992; Pierce et al. 1994b). 

Data from the 1990 California Tobacco Survey 

showed that 46.9 percent of Hispanic smokers had 

not visited a physician in the 12 months before the 

survey, compared with 42.0 percent of Asian Americans and Pacific Islanders, 26.7 percent of African 

Americans, and 33.4 percent of whites (Burns and 

Pierce 1992). According to the 1992 NHIS data on 

Tobacco Control and Education Efforts 283 
 

Surgeon General's Report 

cigarette smokers, 37.6 percent of Hispanics, 26.1 percent of African Americans, and 29.2 percent of whites 

had not visited a physician during the year preceding 

the survey (Tomar et al. 1996). Data from the 1989 NHIS 

on the number of annual visits per person to the dentist 

showed that African American men (1.0 visits) and 

women (1.4 visits) made fewer visits than Hispanic men 

(1.5 visits) and women (1.7 visits) and white men (2.1 

visits) and women (2.4 visits) (Bloom et al. 1992). Among 

smokers, national data collected in 1992 showed that 42.6 

percent of African Americans, 39.3 percent of Hispanics, 

and 54.4 percent of whites had visited a dentist during 

the preceding year (Tomar et al. 1996). In addition, 

because many health care providers lack linguistic skills 

and training in cultural sensitivity, they tend to be 

ineffective advocates of smoking cessation among 

members of ethnic groups. Equally problematic is the 

fact that few physicians have the necessary training, feel 

qualified and supported, or express interest in recommending quitting to smokers (Kottke et al. 1994). 

Available data indicate that a large proportion 

of health care providers, primarily physicians, do not 

take advantage of office visits to encourage smokers 

to quit. In general, members of racial/ethnic groups 

are less likely than whites to receive advice on quitting smoking from their physicians, and they are even 

less likely to receive such advice from their dentists 

(e.g., Kogan et al. 1994; Winkleby et al. 1995; Hymowitz 

et al. 1996). According to data from the 1992–1993 CPS, 

about 42.4 percent of Hispanics and 45.4 percent of 

African Americans who had visited a physician during the previous year reported that within that year 

they had received a physician’s advice on quitting 

smoking, compared with 50.4 percent of whites (Table 

5) (U.S. Bureau of the Census, NCI Tobacco Use Supplement, public use data tapes, 1992–1993). In general, 

women reported receiving a physician’s advice in 

greater proportions than men. When asked if they had 

ever received a physician’s advice on quitting smoking, only 39.8 percent of Hispanics said they had, compared with 47.2 percent of African Americans, 45.7 

percent of Asian Americans and Pacific Islanders, 54.5 

percent of American Indians and Alaska Natives, and 

58.1 percent of whites. Results of the 1991 NHIS show 

that whereas 38.2 percent of whites reported receiving advice to quit from a physician or other health care 

professional at any visit during the preceding 12 

months (CDC 1993a), a percentage significantly higher 

than for Hispanics (30.6 percent), such advice was received by 34.4 percent of African Americans, 41.4 percent of American Indians and Alaska Natives, and 34.4 

percent of Asian Americans and Pacific Islanders. 

According to the 1992 NHIS data on cigarette smokers who had visited a physician during the previous 

year, 55.5 percent of whites, 50.2 percent of African 

Americans, and 35.1 percent of Hispanics reported that 

a physician had advised them to quit smoking during 

the preceding year; among smokers who had visited a 

dentist during the previous year, 23.4 percent of whites, 

26.3 percent of African Americans, and 27.2 percent of 

Hispanics reported that a dentist had advised them to 

quit during the preceding year (Tomar et al. 1996). Because questions were worded differently about advice 

from health care providers on quitting smoking, estimates based on data from the 1991 NHIS and the 1992 

NHIS are not directly comparable and cannot be interpreted as indicating a secular trend. Findings from 

other surveys show that among African Americans, 

pregnant women are the most likely to receive smoking cessation advice and services in a health care setting (O’Campo et al. 1992; Tiedje et al. 1992). 

Results from the 1992 California Tobacco Survey 

showed that among smokers who visited a physician 

in the previous year, 60.9 percent of Hispanics did not 

receive advice on quitting smoking, compared with 

56.0 percent of African Americans and 47.8 percent 

of whites (Pierce et al. 1994b). These figures are 

comparable to those found in the Stanford Five-City 

Multifactor Risk Reduction Project, in which 63.4 

percent of Hispanic smokers reported never being 

advised to quit smoking by their physician, compared 

with 45.9 percent of whites (Frank et al. 1991). These 

differences seem to be particularly notable among less 

educated Hispanics (Winkleby et al. 1995). 

Despite these limitations, the use of health care 

providers to promote smoking cessation can have 

promising results (Royce et al. 1995). The CDC has 

funded the design of protocols that will prescribe strategies health care providers can use when counseling 

patients in smoking cessation, using the Guía for Hispanics and the Pathways to Freedom program for African Americans. In addition, the NCI has produced a 

number of publications reviewing this approach (NCI 

1994) as well as training materials to teach health care 

personnel how to promote smoking cessation (Glynn 

and Manley 1992), and a recent publication has evaluated the effectiveness of various smoking cessation 

approaches available to primary care clinicians (Fiore 

et al. 1996). 

For You and Your Family 

The For You and Your Family project provides 

tobacco-use prevention services to racial/ethnic communities in health care settings. The project, sponsored 

by California’s Department of Health Services, was 

284 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 5.	 Percentage of adult smokers who have received advice to quit smoking from either a medical 

doctor or a dentist, by race/ethnicity and gender, Current Population Survey, United States, 

1992–1993 

African 

Americans 

American Indians/ 

Alaska Natives 

Asian Americans/ 

Pacific Islanders Hispanics Whites 

Characteristic % ±CI* % ±CI % ±CI % ±CI % ±CI 

Received advice from a medical doctor in past year† 

Total 45.4 1.7 48.3 6.2 49.6 5.3 42.4 2.6 50.4 0.7 

Men 42.5 2.6 45.2 9.0 50.1 6.8 39.6 3.6 48.8 1.0 

Women 47.3 2.2 51.0 8.5 48.8 8.6 45.5 3.8 51.7 0.9 

Received advice from a medical doctor ever 

Total 47.2 1.4 54.5 5.3 45.7 4.1 39.8 2.0 58.1 0.6 

Men 40.5 2.1 50.4 7.5 43.7 4.8 33.2 2.5 53.1 0.8 

Women 53.1 2.0 58.6 7.4 50.4 7.5 50.0 3.3 63.1 0.8 

Received advice from a dentist in past year‡ 

Total 20.6 1.8 21.1 6.3 30.5 5.0 22.6 2.6 19.6 0.6 

Men 22.0 2.8 28.5 10.1 36.3 6.4 23.3 3.6 21.4 0.9 

Women 19.6 2.3 14.2 7.5 19.3 7.3 21.7 3.7 18.0 0.8 

Received advice from a dentist ever 

Total 14.7 1.0 18.2 4.1 24.9 3.5 16.7 1.6 18.6 0.4 

Men 15.4 1.5 21.2 6.1 26.7 4.3 15.7 2.0 19.4 0.6 

Women 14.1 1.4 15.2 5.4 20.8 6.1 18.2 2.6 17.8 0.6 

*95% confidence interval. 

†

Among persons who visited a medical doctor during the past year.

‡

Among persons who visited a dentist during the past year.
 

Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
 

1992–1993. 

developed recently by a team of California researchers. This multicultural perinatal project seeks to reduce cigarette smoking among pregnant women and 

to limit their exposure to ETS. The project includes a 

trainer’s guide, a health care provider’s guide, and 

targeted client education materials for African 

Americans, American Indians, Hispanics, and Asian 

Americans (i.e., Cambodians, Chinese, Koreans, and 

Laotians). Materials for clients differ in their content 

and format, depending on the racial/ethnic group being targeted; the materials range from a brochure for 

African Americans entitled Hey, Girlfriend, Let’s Talk 

About Smoking and You to a four-color magazine 

entitled La Mujer: La Familia y el Cigarrillo, which 

motivates Hispanic women to quit and provides suggestions and techniques for quitting and maintaining 

abstinence (Otero-Sabogal and Sabogal 1991). 

The importance of developing smoking cessation 

programs for pregnant women of various races/ 

ethnicities has been documented recently among 

American Indians (Bulterys et al. 1990). By using statistical models with information on the health status 

of American Indians in the Aberdeen IHS area, Bulterys 

and colleagues found that by quitting smoking, American Indian pregnant women would prevent 2.6 percent of all infant deaths, 3.7 percent of postneonatal 

deaths, and 1.2 percent of neonatal deaths. 

Tobacco Control and Education Efforts 285 
 

Surgeon General's Report 

American Indian Cancer Control Project 

The American Indian Cancer Control Project in 

California used self-help techniques, individual counseling, and cultural interventions to help American 

Indian smokers quit. Access to American Indians over 

the age of 18 years was facilitated through 18 northern California clinics owned and operated by American Indians. Fourteen rural clinics located on or near 

reservations and four urban clinics participated in the 

project. The project has been testing a clinic-based, 

physician-initiated message enhanced by using American Indian community health representatives who also 

provide outreach support. Recent data indicate that 

the clinic-based procedures were an acceptable and 

accessible means of reaching the American Indian 

population in northern California (Hodge et al. 1995, 

1996). Evidence from this project suggests the need 

for culturally appropriate smoking cessation programs 

(Hodge et al. 1995). 

Involvement of Employers 

Employer-provided smoking cessation programs 

could help to lower the prevalence of smoking, yet very 

few individuals report having such programs available to them. Data from the 1992–1993 CPS showed 

that 23.6 percent (95 percent confidence interval 

[CI] = ± 0.9 percent) of African Americans reported 

having such services at work, compared with 22.4 percent (CI ± 0.3 percent) of whites, 21.8 percent (CI ± 1.8 

percent) of Asian Americans and Pacific Islanders, 18.8 

percent (CI ± 3.6 percent) of American Indians and 

Alaska Natives, and 15.8 percent (CI ± 0.9 percent) of 

Hispanics (U.S. Bureau of the Census, NCI Tobacco 

Use Supplement, public use data tapes, 1992–1993). 

Among smokers, 25.0 percent (CI ± 1.8 percent) of African Americans, 19.7 percent (CI ± 0.6 percent) of 

whites, 18.4 percent (CI ± 4.1 percent) of Asian Americans and Pacific Islanders, 17.7 percent (CI ± 5.8 percent) of American Indians and Alaska Natives, and 14.3 

percent (CI ± 1.9 percent) of Hispanics reported having access to employer-provided smoking cessation 

services (U.S. Bureau of the Census, NCI Tobacco Use 

Supplement, public use data tapes, 1992–1993). 

Involvement of Nontraditional Providers 

Community members who traditionally have not 

been perceived as health promoters also have become 

involved in tobacco control efforts. For example, African American religious leaders have been involved 

in tobacco control efforts as well as in other health 

promotion activities, such as the National High Blood 

Pressure Education Program (1992). These ministers 

and pastors carry great influence among African 

Americans and are responsible for dictating social and 

moral values. In addition, the church often has been 

central in mobilizing African American communities 

around issues of social justice. Examples of tobacco 

control efforts involving community members, including religious leaders, are presented in this section. 

Unfortunately, little evidence is available about the 

success or effectiveness of this type of intervenor. 

Heart, Body, and Soul is a church-based intervention 

in east Baltimore, Maryland, a predominantly (88 percent) African American community (Stillman et al. 1993; 

Voorhees et al. 1996). Focus groups conducted before 

the intervention revealed that African American smokers were knowledgeable of the health risks of smoking 

but knew few strategies beyond quitting cold turkey. 

The smokers perceived little support for quitting from 

their friends and family, with the exception of their 

children, who tended to be strong motivators to quit 

smoking. The smokers participating in the focus 

groups did not approve of nicotine replacement and 

viewed it as substituting one addiction for another. The 

intervention phase of the study emphasized the importance of self-efficacy to promote behavior change and 

social actions that promote large, systemic, social 

changes as a strategy for affecting individual behavior. The project was carried out through a partnership 

with the local ministerial alliance. Of 130 churches in 

the area, 22 participated in the intervention. 

After introductory activities, which included a 

health fair, churches were randomly assigned to receive either an intensive smoking cessation intervention or the minimal level of activity, which involved 

distribution of the ALA educational brochure Don’t Let 

Your Dreams Go Up in Smoke (ALA 1990a). Churches 

participating in the intervention received the same 

brochure but also were involved in the following activities: (1) training of smoking cessation specialists, 

who conducted weekly support groups with a spiritual overtone; (2) a kickoff service that included an 

inspirational sermon, distribution of One Day at a Time 

(a Scripture-based book of inspirational messages for 

smokers), and an inspirational audiocassette on quitting smoking; and (3) reinforcement of successful quitting through recognition during church services and 

the provision of certificates to volunteers participating in the program. The program is now being 

extended to churches in 13 cities throughout the country. As a result of this program, a number of African 

American clergy have formed a coalition, Black Clergy 

286 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

for Substance Abuse Prevention, to implement tobacco 

control programs and other substance abuse prevention efforts. The coalition is affiliated with the National 

Association of African Americans for Positive 

Imagery (NAAAPI). A recent study showed that 

church-based programs can be effective in moving individuals along the continuum of change toward 

quitting smoking (Schorling et al. 1997). 

Innovative programs are also under way in 

California. In San Diego, the Union of Pan Asian Communities of San Diego County delivers antismoking 

messages through fortune cookies (Irene LinayaoPutman, personal communication, 1993). The St. Mary 

Medical Center and the United Cambodian Community, Inc., in Long Beach, California, developed 

audiocassettes that feature traditional Laotian and 

Cambodian music as well as antismoking messages. 

These audiocassettes are distributed through racial/ 

ethnic shops, health fairs, and other community events. 

Barbers and beauty parlor operators also have been 

trained to provide antismoking messages to their clients in small community programs in California and 

other states. 

Although not all of these smoking cessation interventions are culturally appropriate, preliminary 

figures on the overall effectiveness of these massive 

interventions show that progress is being made in a 

number of areas. In California, for example, the overall prevalence of smoking has declined, more smoking cessation services are available, people are more 

aware of the dangers of cigarette smoking, and increases in adolescent smoking appear to have stopped 

(Breslow and Johnson 1993; Pierce et al. 1994b; Elder 

et al. 1996). These results are true for members of 

racial/ethnic minority groups as well as for whites. 

Environmental Tobacco Smoke and Clean Indoor Air Policies
 

A large number of individuals from racial/ 

ethnic groups work in the service industry (e.g., restaurants) and in blue-collar jobs (e.g., factories and 

repair shops)—areas of employment where cigarette 

smoking usually is allowed. Thus, they are probably 

heavily exposed to ETS. 

Although the data are incomplete, a few studies 

indicate the extent to which nonsmokers, particularly 

those who are members of racial/ethnic groups, are 

exposed to ETS. Data from the 1993 California Tobacco 

Survey showed that 32.0 percent of nonsmoking Hispanics were exposed to ETS at indoor workplaces, 

compared with 19.1 percent of African Americans and 

19.0 percent of whites (Pierce et al. 1994b). 

Exposure to ETS at home is also a concern among 

members of racial/ethnic groups. Data from the 1992– 

1993 CPS (Table 6) showed that a majority of Asian 

Americans and Pacific Islanders (60.6 percent) and Hispanics (56.6 percent) did not allow cigarette smoking 

in their homes (U.S. Bureau of the Census, NCI 

Tobacco Use Supplement, public use data tapes, 1992– 

1993). In comparison, smaller proportions of whites 

(41.3 percent), African Americans (38.9 percent), and 

American Indians and Alaska Natives (35.6 percent) 

reported that they prohibited smoking at home. Minor gender differences were observed in the reporting 

of such restrictions. Other surveys indicate that exposure to tobacco smoke at home is a valid concern. 

An analysis of data from the Hispanic Health and 

Nutrition Examination Survey indicates that 31 to 62 

percent of Mexican American nonsmoking women had 

household exposure to ETS (Pletsch 1994). In addition, 22 to 59 percent of Puerto Rican women and 40 to 

53 percent of Cuban American women had such exposure. 

In recent years, businesses and governments have 

adopted policies, laws, and ordinances that limit cigarette smoking in public places and in workplaces 

(Rigotti and Pashos 1991). The effects of these policies 

can be expected to benefit all U.S. residents, including 

members of racial/ethnic minority groups. In addition, systemwide antismoking policies are being promulgated. For example, no-smoking policies have 

been implemented in a number of federal workplaces, 

including IHS hospitals and clinics and Department 

of Defense installations. States have also been restricting smoking at a fairly rapid pace by banning smoking on public transportation vehicles as well as in 

health care offices and facilities, airports, other public 

buildings, and elevators (O’Connor 1992). A number 

of states also restrict smoking in indoor cultural and 

recreational facilities, including libraries, museums, 

Tobacco Control and Education Efforts 287 
 

Surgeon General's Report 

Table 6.	 Percentage of adults who reported that no one is allowed to smoke anywhere inside the home,* 

by race/ethnicity, smoking status, and gender, Current Population Survey, United States, 

1992–1993

Characteristic 

African 

Americans ____________ 

% ±CI† 

American Indians/ 

Alaska Natives _________________ 

% ±CI 

Asian Americans/ 

Pacific Islanders 

_______________ 

% ±CI 

Hispanics _____________ 

% ±CI 

Whites ___________ 

% ±CI 

Overall 

Total 38.9 0.7 35.6 3.2 60.6 1.6 56.6 0.9 41.3 0.3 

Men 37.7 1.1 34.1 4.7 57.9 2.3 54.3 1.3 41.2 0.4 

Women 39.6 0.9 36.8 4.3 63.2 2.2 58.5 1.2 41.4 0.4 

Nonsmokers 

Total 49.9 0.9 53.4 4.2 67.3 1.6 64.5 1.0 51.7 0.3 

Men 50.2 1.4 54.1 6.6 66.7 2.5 63.6 1.5 51.6 0.5 

Women 49.8 1.1 52.9 5.5 67.8 2.2 65.2 1.2 51.8 0.4 

Smokers 

Total 7.4 0.8 7.9 2.9 25.2 3.5 21.6 1.7 10.1 0.3 

Men 9.2 1.2 8.7 4.2 28.5 4.4 26.7 2.4 12.4 0.5 

Women 5.9 0.9 7.1 3.9 17.5 5.7 13.9 2.3 7.8 0.4 

*Includes persons who reported having a rule that no one is allowed to smoke anywhere inside the home.

†

95% confidence interval.
 

Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
 

1992–1993.
 

theaters, galleries, shopping malls, sports arenas, and 

auditoriums. An ever-increasing number of states have 

restricted smoking in schools and on school grounds 

for students, school personnel, and other persons with 

access to the school; 27 states restrict smoking in child 

day-care centers. As of December 31, 1997, 41 states 

have some kind of restriction on smoking in government worksites, 21 have restrictions on smoking in private worksites, and 31 restrict smoking in restaurants 

(CDC, Office on Smoking and Health, State Tobacco Activities Tracking and Evaluation System, unpublished 

data). 

An increasing number of employers are also restricting cigarette smoking. In the 1992–1993 CPS, a 

substantial proportion of respondents reported that 

their employers had policies prohibiting cigarette 

smoking in work areas and in indoor public areas, such 

as lobbies, rest rooms, and lunch rooms. Gerlach and 

colleagues (1997) used data from the 1992–1993 NCI 

Tobacco Use Supplement to the CPS to document the 

prevalence and restrictiveness of workplace smoking 

policies reported by African Americans, Asian Americans and Pacific Islanders, Hispanics, and whites who 

were employed in indoor workplaces. Their data 

showed that 43.3 percent of African Americans, 51.4 

percent of Asian Americans and Pacific Islanders, 45.1 

percent of Hispanics, and 46.2 percent of whites 

worked for employers who provided smoke-free 

policies. In all four groups, women were more likely 

than men to be protected by smoke-free policies. Overall, about one-third of employees worked in places that 

either had no policy on smoking or allowed smoking 

in private work areas. These minimal policies were 

reported by 33.9 percent of African Americans, 29.7 

percent of Asian Americans and Pacific Islanders, 37.3 

percent of Hispanics, and 35.6 percent of whites. This 

report did not present data on American Indians and 

Alaska Natives. 

Members of the racial/ethnic minority groups 

considered in this report tend to favor restrictions on 

tobacco smoking (see Royce et al. 1993 for data on 

African Americans). In the 1992–1993 CPS, Asian 

Americans and Pacific Islanders and Hispanics were 

generally more likely to support the total restriction 

of cigarette smoking in restaurants, hospitals, indoor 

workplaces, and indoor shopping malls (Table 7) (U.S. 

Bureau of the Census, NCI Tobacco Use Supplement, 

public use data tapes, 1992–1993). Smokers were more 

288 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

likely to agree with partial restrictions of cigarette 

smoking (limiting smoking to some areas within each 

enclosed space) than to support the total restriction of 

cigarette smoking in each of the public places included 

in the CPS. Results of an ABC News/The Washington 

Post poll conducted in February 1993 showed that 

larger proportions of African Americans (54.3 percent) 

and Hispanics (52.9 percent) favored banning smoking in public places, compared with whites (48.3 percent) (Roper Center for Public Opinion Research 1993). 

The same poll showed that fairly similar proportions 

of Hispanics (87.9 percent), African Americans (84.3 

percent), and whites (84.1 percent) felt that ETS was a 

health risk. However, Hispanics (50.8 percent) and 

African Americans (44.2 percent) reported worrying 

more about ETS than whites (34.4 percent). 

Data from the 1992 California Tobacco Survey 

showed that members of racial/ethnic groups had limited support for the complete ban of cigarette smoking in restaurants and in workplaces (Pierce et al. 

1994a). For example, smoking bans in restaurants drew 

support from 53.5 percent of Hispanics, 41.9 percent 

of African Americans, 35.0 percent of Asian Americans 

and Pacific Islanders, and 34.7 percent of whites. The 

data on smoking bans in the workplace were similar. 

Hispanics (54.5 percent) were more likely to support 

banning cigarette smoking in the workplace than were 

Asian Americans and Pacific Islanders (43.5 percent), 

African Americans (40.2 percent), and whites (34.4 

percent). 

More recently, findings from a 1993 survey indicate that residents of eight California cities (Fresno, 

Hercules, Indio, Los Angeles, Paradise, Sacramento, 

San Bernardino, and San Diego) significantly supported strong ETS controls (Sherwood et al. 1994). In 

this 1993 survey, 78 percent of whites supported a complete ban on smoking in restaurants, compared with 

91.4 percent of Asian Americans, 89.5 percent of Hispanics, 82.6 percent of American Indians, and 82.5 percent of African Americans. In addition, 84.5 percent 

of whites strongly supported a complete ban on smoking in the workplace, compared with 93.5 percent of 

Asian Americans, 92.0 percent of Hispanics, 87.9 percent of African Americans, and 85.6 percent of American Indians. 

The degree to which existing no-smoking policies are enforced in racial/ethnic communities is 

unknown. In a recent survey of 39 American Indian 

tribes, Glasgow and colleagues (1995) found significant intertribal variations in the types of policies and 

places covered by clean indoor air policies. For 

example, 64 percent of the tribes reported having a nosmoking policy that designated tribal schools, council 

meeting areas, and private offices as nonsmoking areas, but none banned smoking in bingo halls. Those 

tribes that received a specially developed policy workbook and direct consultation on ways to implement 

tobacco control policies were found to have adopted 

stringent policies within two years of having received 

the intervention materials (Lichtenstein et al. 1995). A 

recent observational study of American Indian facilities in California, Idaho, New Mexico, New York, Oregon, and Washington found that smoking policies 

and practices varied considerably across settings (Hall 

et al. 1995). Tribal schools and Indian health care facilities had the most restrictive policies. Tribal council 

meeting areas and private offices were less likely to be 

designated nonsmoking areas. No-smoking signs were 

observed most frequently in clinics (46 percent) and 

tribal offices (37 percent); no-smoking posters also were 

prominent in clinics (49 percent). Evidence of smoking (e.g., persons smoking, cigarette stubs, and ashtrays) was observed most frequently in tribal offices 

and cultural centers or community buildings (Hall et 

al. 1995). 

A number of programs have tried to promote 

clean indoor air policies and practices among members of the racial/ethnic minority groups included in 

this report, but little information is available on their 

effectiveness. For example, Asian Americans for Community Involvement of Santa Clara County, based in 

San Jose, California, has targeted 400 Asian American 

restaurants and businesses to encourage them to have 

smoke-free areas. However, the researchers had difficulties assuring Asian American merchants that providing smoke-free areas would be good for business 

(Jung 1993). 

Among American Indians, efforts have been 

made to help various tribes develop comprehensive 

smoke-free programs. For example, Glasgow and colleagues (1995) worked with 39 tribes in Washington, 

Oregon, and Idaho to review, modify, and develop 

tobacco-use policies that would protect tribal members from ETS. Tobacco policy committees were established to advise tribes during the policymaking 

process. A tobacco policy workbook also was developed to guide the tribes. Although tribal leaders 

expressed support for more stringent tobacco-use 

policies, changes in tobacco policies were not produced 

through the tobacco policy committees as the project 

had originally planned. 

Tobacco Control and Education Efforts 289 
 

Surgeon General's Report 

Table 7.	 Percentage of adults who think that smoking should be allowed in some areas or not allowed at 

all in selected public locations,* by race/ethnicity and smoking status, Current Population Survey, 

United States, 1992–1993 

African 

Americans 

% ±CI† 

American Indians/ 

Alaska Natives 

% ±CI 

Asian Americans/ 

Pacific Islanders 

% ±CI 

Hispanics 

% ±CI 

Whites 

Characteristic % ±CI

 Restaurants (allowed in some areas) 

Total 50.8 0.7 52.4 3.3 42.1 1.6 38.1 0.9 52.9 0.3 

Nonsmokers 44.3 0.9 39.1 4.1 37.6 1.7 33.5 0.9 44.4 0.3 

Smokers 69.5 1.3 73.4 4.7 66.4 3.9 58.8 2.1 78.6 0.5

 Hospitals (allowed in some areas) 

Total 22.8 0.6 26.6 2.9 12.8 1.1 12.9 0.6 25.8 0.2 

Nonsmokers 18.5 0.7 15.6 3.1 11.2 1.1 10.5 0.6 19.0 0.3 

Smokers 35.0 1.4 44.3 5.3 21.7 3.4 23.4 1.8 46.3 0.6

 Indoor work areas (allowed in some areas) 

Total 39.3 0.7 43.9 3.3 24.7 1.4 25.8 0.8 40.7 0.3 

Nonsmokers 32.6 0.8 30.1 3.9 21.0 1.4 21.6 0.8 32.4 0.3 

Smokers 58.5 1.4 65.8 5.0 44.3 4.1 44.1 2.1 65.5 0.5

 Restaurants (not allowed) 

Total 45.3 0.7 42.5 3.3 54.5 1.6 58.8 0.9 43.1 0.3 

Nonsmokers 53.0 0.9 58.7 4.2 59.8 1.7 64.2 1.0 52.9 0.3 

Smokers 23.5 1.2 16.9 4.0 25.9 3.6 34.9 2.0 13.6 0.4

 Hospitals (not allowed) 

Total 75.3 0.6 71.3 3.0 85.1 1.1 85.7 0.6 72.5 0.3 

Nonsmokers 80.0 0.7 83.5 3.2 86.9 1.2 88.3 0.6 79.9 0.3 

Smokers 62.0 1.4 51.8 5.3 75.8 3.5 74.2 1.8 50.6 0.6 

Indoor work areas (not allowed) 

Total 57.0 0.7 52.2 3.3 71.8 1.4 70.9 0.8 55.7 0.3 

Nonsmokers 64.6 0.8 68.3 4.0 75.8 1.5 75.7 0.9 65.1 0.3 

Smokers 35.6 1.4 26.5 4.7 50.5 4.1 50.3 2.1 27.6 0.5 

*In response to the question about each place, “Do you think that smoking should be allowed in all areas, in some 

areas, or not allowed at all?” 

†

95% confidence interval.
 

Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
 

1992–1993.
 

290 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 7. Continued 

African 

Americans 

% ±CI 

American Indians/ 

Alaska Natives 

% ±CI 

Asian Americans/ 

Pacific Islanders 

% ±CI 

Hispanics 

% ±CI 

Whites 

Characteristic % ±CI

 Bars and cocktail lounges (allowed in some areas) 

Total 44.2 0.7 36.6 3.2 45.7 1.6 38.8 0.9 44.0 0.3 

Nonsmokers 44.2 0.9 38.5 4.1 46.4 1.8 39.0 1.0 44.9 0.3 

Smokers 44.3 1.4 33.3 5.0 42.2 4.0 37.8 2.0 41.3 0.6

 Indoor sporting events (allowed in some areas) 

Total 30.3 0.7 25.8 2.9 23.0 1.4 22.4 0.7 28.7 0.3 

Nonsmokers 27.1 0.8 17.9 3.3 21.1 1.4 20.2 0.8 23.9 0.3 

Smokers 39.2 1.4 38.2 5.2 32.8 3.8 31.9 1.9 43.3 0.6

 Indoor shopping malls (allowed in some areas) 

Total 39.9 0.7 40.8 3.3 32.3 1.5 28.2 0.8 41.6 0.3 

Nonsmokers 35.7 0.8 31.7 4.0 29.1 1.6 25.2 0.9 35.2 0.3 

Smokers 51.7 1.4 54.8 5.3 49.5 4.1 41.3 2.1 61.2 0.6

 Bars and cocktail lounges (not allowed) 

Total 25.6 0.6 22.2 2.8 29.8 1.5 31.3 0.8 22.6 0.2 

Nonsmokers 31.8 0.8 33.2 4.0 33.5 1.7 35.6 1.0 28.8 0.3 

Smokers 8.1 0.8 5.2 2.4 9.6 2.4 12.1 1.4 4.0 0.2

 Indoor sporting events (not allowed) 

Total 64.5 0.7 68.2 3.1 72.3 1.4 72.9 0.8 65.9 0.3 

Nonsmokers 68.9 0.8 79.3 3.4 74.8 1.5 75.8 0.9 72.3 0.3 

Smokers 52.5 1.4 50.5 5.3 59.5 4.0 60.0 2.0 46.5 0.6

 Indoor shopping malls (not allowed) 

Total 54.4 0.7 52.3 3.3 62.7 1.6 67.2 0.8 52.6 0.3 

Nonsmokers 59.7 0.8 65.2 4.0 66.5 1.7 70.8 0.9 60.6 0.3 

Smokers 39.7 1.4 32.3 5.0 42.7 4.0 51.3 2.1 28.6 0.5 

Tobacco Control and Education Efforts 291 
 

Surgeon General's Report 

Economic Efforts to Reduce Tobacco Use 

Numerous efforts have been made to reduce the 

use of cigarettes through excise and sales taxes. Because these taxes increase the price of cigarettes, higher 

tax rates generally curb the demand for cigarettes, and 

ultimately, tobacco consumption (Grossman 1989; 

Peterson et al. 1992; Keeler et al. 1993; Townsend et al. 

1994). Peterson and colleagues (1992) evaluated the 

effects of state cigarette tax increases on cigarette sales 

in the 50 states from 1985 through 1988. The researchers found that state cigarette tax increases were 

associated with an average decline in cigarette consumption of three cigarette packs per capita (a decline 

of about 2.4 percent). Likewise, larger tax increases 

were associated with larger declines in consumption. 

In a recent study in Britain, Townsend and colleagues 

(1994) found that individuals of low-socioeconomic 

status were more responsive to changes in the price of 

cigarettes than those who were more affluent. 

As of June 30, 1996, all states, the District of Columbia, and 451 localities currently impose taxes on 

cigarettes in addition to the federal tax (Tobacco Institute 1997). As of December 31, 1997, state taxes ranged 

from a low of 2.5 cents in Virginia to a high of $1 in 

Alaska; the average state tax was 37.76 cents per pack 

(CDC, Office on Smoking and Health, State Tobacco 

Activities Tracking and Evaluation System, unpublished data). 

Members of some racial/ethnic minority groups 

have supported increases in taxes for tobacco products. In a 1990 survey of California smokers, 29.1 percent of African American smokers and 34.5 percent of 

Hispanic smokers reported that they would support a 

cigarette tax increase (Burns and Pierce 1992). A much 

smaller proportion of whites who smoke (20.0 percent) 

supported such an increase. Recently, larger proportions of California adults have supported an increase 

in cigarette taxes. The 1992 California Tobacco Survey among both smokers and nonsmokers found that 

cigarette tax increases were supported by 60.2 percent 

of Asian Americans and Pacific Islanders, 50.4 percent 

of Hispanics, 49.5 percent of African Americans, and 

49.8 percent of whites (Pierce et al. 1994a). Furthermore, a 1993 nationwide survey conducted for the ACS 

found that Hispanics (71 percent) and African Americans (63 percent) supported an increase of $2 per pack 

to pay for a national health insurance program (Marttila 

& Kiley, Inc. 1993). These proportions were fairly 

similar to those found among whites (66 percent). 

Although tobacco taxes are effective in discouraging smoking, some people consider increases in 

excise taxes to be regressive because the poorer 

members of society pay a higher proportion of their 

income in taxes. Wasserman (1992), for example, states: 

With respect to excise tax increases, however, we 

must be mindful of the distributional consequences of higher taxes. More precisely, because 

low-income smokers do not appear to be any more 

responsive to higher cigarette prices than highincome smokers, higher excise taxes will result in 

disproportionate economic harm, and, in some 

cases, could lead poorer smokers to forgo food, 

shelter, and needed health care to fulfill the persistent and pernicious demands of their smoking 

habits. As a result, higher cigarette taxes should 

be accompanied by measures to compensate the 

poor for the larger burden that they will necessarily have to bear. For example, federal and state 

income tax structures could be modified to facilitate such compensation (p. 20). 

A 1990 federal government report supported this 

argument by presenting data from the 1984–1985 

Consumer Expenditure Survey Interview showing that 

families in the lowest income quintile spent 4 percent 

of their posttax income on tobacco products, compared 

with families in the highest quintile, who spent 0.5 

percent of their posttax income on tobacco products 

(U.S. Congressional Budget Office 1990). On the other 

hand, some argue that the hardship of increased taxes 

on the poor is outweighed by the fact that smokingrelated health costs and suffering decline among 

persons who smoke fewer cigarettes or stop smoking 

because of the higher taxes on tobacco. A group of 

economists meeting in 1995 concluded that additional 

research on costs is needed before an optimal cigarette 

excise tax from an economic perspective can be determined (Warner et al. 1995). These economists agreed 

that the strongest argument currently for increasing 

cigarette taxes is the protection of children. 

The actual effects of excise tax initiatives on members of racial/ethnic minority groups are difficult to 

ascertain. Nevertheless, reductions in the consumption 

of tobacco products resulting from increases in excise 

taxes should ultimately benefit members of U.S. 

racial/ethnic groups by lowering their prevalence of 

292 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

cigarette smoking and by limiting or lowering their funded through the revenue generated by the increased 

exposure to ETS. California’s experience after increas- taxes (Breslow and Johnson 1993). In addition, given 

ing the tax on cigarettes shows that a number of the need to help community-based programs and orcommunity-based projects, school-based interventions, ganizations rely less on tobacco industry support 

and research activities, which directly benefit members (Satcher and Robinson 1994), earmarked tax revenues 

of the racial/ethnic groups and could not have been may prove to be a viable alternative. 

funded from other sources of tax revenue, can be 

Efforts to Control Tobacco Advertising and Promotion 

Tobacco products are heavily advertised in 

racial/ethnic publications and in racial/ethnic communities. Efforts to restrict the effects of advertising 

and promotion of tobacco products in racial/ethnic 

communities have been limited by various factors, 

including the communities’ reliance on the tobacco 

industry (see Chapter 4), difficulties in mobilizing communities that are faced with problems perceived to be 

in need of more immediate attention (e.g., affordable 

housing, unemployment, unequal education, and 

racial/ethnic minority discrimination), the lack of 

trained community leaders interested in health issues, 

and possibly the lack of infrastructure for tobacco prevention and control initiatives in racial/ethnic communities (Robinson et al. 1995). As a result, persons 

residing in racial/ethnic communities are continually 

exposed to the advertising and promotion of tobacco 

products. A recent study in Los Angeles County, for 

example, examined the risk of exposure to outdoor 

advertising of cigarettes among residents of various 

communities (Ewert and Alleyne 1992). The results 

suggest that persons residing in the city of Los Angeles 

were more likely to be exposed to cigarette and alcohol 

billboard advertisements than residents of nearby suburbs. Cigarettes were advertised on 59 of the 299 billboards (19.7 percent) surveyed on 46.2 miles of streets. 

The number of cigarette advertisements was 4.6 times 

greater in the city of Los Angeles than in its suburbs. 

Members of some racial/ethnic minority groups 

tend to be more likely than whites to support a ban on 

tobacco product advertisements (Table 8). Data from 

the 1992–1993 CPS showed that 37.5 percent of whites 

supported a ban on advertising tobacco products, compared with 44.7 percent of Hispanics, 39.5 percent of 

Asian Americans and Pacific Islanders, and 38.3 percent of African Americans (U.S. Bureau of the Census, 

NCI Tobacco Use Supplement, public use data tapes, 

1992–1993). In each racial/ethnic group, women and 

nonsmokers were more supportive of a total ban on 

tobacco advertising than were men and smokers. The 

1992 California Tobacco Survey found that adult Californians supported the banning of such advertising 

in newspapers and magazines as well as on billboards 

(Table 9) (Pierce et al. 1994a). The same survey also 

showed support for banning tobacco companies from 

sponsoring cultural events. Hispanics tend to show 

the greatest level of support for these measures, 

whereas whites support them the least. Data from the 

1992–1993 CPS also showed that fairly large percentages of racial/ethnic group members would support 

a ban on the free distribution of tobacco samples 

(Table 10) (U.S. Bureau of the Census, NCI Tobacco 

Use Supplement, public use data tapes, 1992–1993). 

Hispanics (59.4 percent) and Asian Americans and 

Pacific Islanders (57.5 percent) were the most likely 

respondents to state that they supported such a ban. 

In all groups, women and nonsmokers were more 

likely than men and smokers to favor the ban. 

The 1994 RWJF Youth Access Survey (Table 4) 

found varying support for restricting or banning different types of tobacco advertising. Hispanics and 

African Americans were more likely than whites to 

support such proposals (Nancy Kaufman et al., unpublished data). Hispanics were more supportive of 

bans on billboard, newspaper, and magazine advertising than were African Americans and whites. Requiring plain packaging of tobacco products (brand 

name and warning label in black letters on white 

background) was supported substantially more by 

Hispanics than by African Americans or whites. 

In recent years, the tobacco industry has shifted 

expenditures for advertising to promotional marketing, with 89 percent of 1995 expenditures devoted to 

nonadvertising promotions (Federal Trade Commission 1997). The RWJF Youth Access Survey found that 

broad-based support exists for eliminating coupon 

Tobacco Control and Education Efforts 293 
 

Surgeon General's Report 

Table 8.	 Percentage of adults who think that the advertising of tobacco products should be always allowed 

or not allowed at all,* by race/ethnicity, smoking status, and gender, Current Population Survey, 

United States, 1992–1993 

African 

Americans 

American Indians/

Alaska Natives

 Asian Americans/ 

 Pacific Islanders Hispanics Whites 

Characteristic % ±CI† % ±CI % ±CI % ±CI % ±CI 

Total 

Always 17.3 0.6 21.5 2.7 12.6 1.1 13.7 0.6 21.4 0.2 

Not at all 38.3 0.7 36.6 3.2 39.5 1.6 44.7 0.9 37.5 0.3 

Men 

Always 19.8 0.9 24.0 4.2 15.6 1.7 16.8 1.0 25.5 0.4 

Not at all 35.2 1.1 30.5 4.5 35.9 2.2 39.2 1.3 32.9 0.4 

Women 

Always 15.7 0.7 19.4 3.5 9.7 1.3 11.2 0.8 17.9 0.3 

Not at all 40.3 0.9 41.6 4.4 43.0 2.2 49.2 1.2 41.5 0.4 

Nonsmokers 

Always 13.6 0.6 13.0 2.9 10.5 1.1 11.4 0.6 16.7 0.2 

Not at all 42.2 0.8 44.3 4.2 41.8 1.7 47.8 1.0 42.0 0.3 

Men 

Always 16.5 1.0 15.6 4.8 13.4 1.8 14.0 1.1 20.7 0.4 

Not at all 38.3 1.4 38.1 6.4 38.3 2.5 42.3 1.5 37.0 0.5 

Women 

Always 11.8 0.7 11.2 3.5 8.2 1.3 9.6 0.8 13.4 0.3 

Not at all 44.5 1.1 48.7 5.6 44.7 2.4 51.6 1.3 46.3 0.4 

Smokers 

Always 28.2 1.3 34.7 5.1 23.7 3.5 24.0 1.8 35.6 0.5 

Not at all 27.2 1.3 24.3 4.6 27.5 3.6 31.1 1.9 23.9 0.5 

Men 

Always 27.5 1.9 34.8 7.1 23.2 4.1 25.4 2.3 38.8 0.8 

Not at all 28.1 1.9 20.1 6.0 28.1 4.4 29.9 2.5 21.5 0.7 

Women 

Always 28.7 1.8 34.5 7.2 25.0 6.5 21.9 2.8 32.4 0.7 

Not at all 26.5 1.7 28.5 6.8 26.1 6.6 32.9 3.1 26.2 0.7 

*In response to the question, “Do you think advertising of tobacco products should be always allowed, allowed 

under some conditions, or not allowed at all?” 

†95% confidence interval.
 

Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
 

1992–1993. 

promotions, such as promotional gear or free cigarettes 

by mail (Nancy Kaufman et al., unpublished data). 

Hispanics continue to be more supportive of promotional bans than non-Hispanics, with 89.8 percent of 

Hispanics supporting elimination of coupons for obtaining free cigarettes by mail, compared with 79.5 

percent of African Americans and 80.4 percent of 

whites. In addition, 82.4 percent of Hispanics favor 

elimination of cigarette pack coupons that can be exchanged for promotional items such as clothing, compared with 76.5 percent of African Americans and 67.8 

percent of whites. The public is more ambivalent about 

not allowing tobacco company sponsorship of sporting or entertainment events in which their cigarette 

brand names are featured during television broadcasts. 

Hispanics were more supportive of such a ban than 

were African Americans and whites (Table 4). 

Racial/ethnic minority communities have begun 

to respond to the tobacco industry’s targeted advertising and marketing efforts by mobilizing against the 

industry. The strong community response in Philadelphia against the planned introduction of Uptown 

294 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 9.	 Percentage of Californians* who support curtailment of tobacco advertising and promotion 

efforts, by race/ethnicity, 1992 

Curtailment 

African 

Americans 

Asian Americans/ 

Pacific Islanders Hispanics Whites 

Ban advertising in newspapers 

and magazines 60.2 51.2 74.7 47.7 

Ban advertising on billboards 64.9 57.6 78.1 54.9 

Ban sponsorship of sporting or 

cultural events 63.7 59.4 70.1 50.7 

*Data on American Indians and Alaska Natives are not reported because of small sample size. 

Source: Pierce et al. 1994a. 

cigarettes, a brand targeting African Americans, resulted in the cancellation of the test marketing of the 

cigarette by its producers and a renewed interest in 

tobacco control efforts among African Americans in 

Philadelphia (see Chapter 4). The Coalition Against 

Uptown Cigarettes, which led the campaign, succeeded by building on previous efforts by Philadelphia organizations and individuals to control tobacco 

use among the city’s African Americans. These organizations include some African American clergy as well 

as voluntary associations, particularly the ALA and 

the ACS, the Fox Chase Cancer Center, the local 

Committee to Prevent Cancer among Blacks, and the 

Philadelphia chapter of the National Black Leadership 

Initiative on Cancer (NBLIC). Indeed, the NBLIC in 

Philadelphia served as a common meeting ground 

for leaders from various agencies and provided opportunities for the development of mutual trust needed 

during the campaign. The NBLIC had been formed 

several years before under the leadership of Louis W. 

Sullivan, M.D., then and now president of Morehouse 

School of Medicine. Subsequently, Dr. Sullivan provided strong support to the coalition’s efforts in his 

role as Secretary of Health and Human Services. The 

fact that the Uptown coalition was led by African 

Americans in this historic benchmark in the tobacco 

control movement was central to its ultimate success. 

Moreover, the participation of Philadelphia’s African 

American clergy and the participation of an African 

American minister as a key coalition spokesperson 

were critical in obtaining community support for the 

Coalition Against Uptown Cigarettes. This support 

added to the campaign’s credibility and guaranteed 

its success as a grassroots communications vehicle. 

The experience of the Coalition Against Uptown 

Cigarettes is significant not only for the result it 

achieved but also because it provides a case study in 

community mobilization. The coalition focused its efforts primarily on African Americans—both smokers 

and nonsmokers—with the goal of derailing the introduction of Uptown cigarettes by convincing smokers 

to refuse to sample the new brand. To accomplish this, 

the coalition crafted messages that targeted R.J. 

Reynolds rather than smokers. In addition, the coalition aimed at forming a partnership among African 

American smokers and nonsmokers around the issue 

of limiting minors’ access to this new tobacco product. 

Also central to the success of the Coalition Against 

Uptown Cigarettes was its strategic use of mass media 

(Robinson and Sutton, in press). Coalition leaders expanded the debate beyond health; identified the tobacco 

industry’s major positions related to economics, civil 

rights, and self-determination; and developed specific 

counterarguments. For example, when tobacco industry supporters argued that tobacco control advocates 

were taking away smokers’ right of free choice, coalition spokespersons countered by stating that the 

community had not asked for Uptown cigarettes, that 

excessive billboard advertising of cigarettes in African 

American communities did indeed take away choices, 

that smokers had the right to choose to reject Uptown 

cigarettes, and that communities had the right to choose 

what products entered their neighborhoods. 

Another example of community mobilization in 

tobacco control occurred early in 1995, when a new 

mentholated cigarette brand named “X” being marketed in Boston was withdrawn by its manufacturer 

and distributor after protests by the African American 

community, led by the NAAAPI and Boston-based 

Churches Organized to Stop Tobacco (COST) (Jackson 

1995). X cigarettes were packaged in the Afrocentric 

colors red, black, and green and featured a prominent 

Tobacco Control and Education Efforts 295 
 

Surgeon General's Report 

Table 10.	 Percentage of adults who think that giving away free tobacco samples should be always allowed or 

not allowed at all,* by race/ethnicity, smoking status, and gender, Current Population Survey, United 

States, 1992–1993 

African 

Americans 

American Indians/

Alaska Natives

 Asian Americans/ 

 Pacific Islanders Hispanics Whites 

Characteristic % ±CI† % ±CI % ±CI % ±CI % ±CI 

Total 

Always 11.4 0.5 12.8 2.2 6.9 0.8 7.7 0.5 12.2 0.2 

Not at all 49.9 0.7 49.9 3.3 57.5 1.6 59.4 0.9 54.3 0.3 

Men 

Always 13.4 0.8 14.6 3.5 9.1 1.3 9.9 0.8 15.3 0.3 

Not at all 46.8 1.2 46.4 4.9 52.2 2.3 53.8 1.3 48.9 0.4 

Women 

Always 10.0 0.6 11.2 2.8 4.8 1.0 5.8 0.6 9.4 0.2 

Not at all 52.0 0.9 52.9 4.5 62.7 2.2 63.9 1.2 59.1 0.4 

Nonsmokers 

Always 7.7 0.5 6.8 2.1 5.3 0.8 5.9 0.5 8.4 0.2 

Not at all 55.9 0.9 61.2 4.1 61.0 1.7 63.5 1.0 62.2 0.3 

Men 

Always 9.4 0.8 8.1 3.6 7.1 1.3 7.8 0.8 11.2 0.3 

Not at all 52.6 1.4 57.8 6.5 55.9 2.6 58.6 1.5 56.3 0.5 

Women 

Always 6.8 0.5 5.8 2.6 3.9 0.9 4.6 0.5 6.0 0.2 

Not at all 57.9 1.1 63.7 5.3 65.1 2.3 66.9 1.2 67.3 0.4 

Smokers 

Always 21.8 1.2 22.1 4.4 15.7 3.0 15.5 1.5 23.6 0.5 

Not at all 33.3 1.4 32.1 5.0 38.9 4.1 41.1 2.1 30.6 0.5 

Men 

Always 22.5 1.8 22.8 6.3 16.5 3.6 16.4 2.0 26.9 0.7 

Not at all 33.9 2.0 31.3 7.0 39.2 4.8 39.1 2.6 28.4 0.7 

Women 

Always 21.1 1.6 21.3 6.2 13.8 5.2 14.1 2.3 20.5 0.6 

Not at all 32.7 1.9 32.9 7.1 38.4 7.3 44.1 3.3 32.9 0.7 

*In response to the question, “Do you think that giving away free samples by tobacco companies should be always 

allowed, allowed under some conditions, or not allowed at all?” 

†95% confidence interval.
 

Source: U.S. Bureau of the Census, National Cancer Institute Tobacco Use Supplement, public use data tapes,
 

1992–1993. 

“X,” a symbol associated with African American leader 

Malcolm X. Although X cigarettes were manufactured 

and distributed by two relatively small companies with 

modest marketing efforts, African American community leaders feared that even a small success could fuel 

the creation of similar products by major tobacco companies with larger resources for advertising and 

promotion. Unlike the case of Uptown cigarettes, 

however, both the manufacturer and the distributor 

of X cigarettes denied that their product was targeted 

to an African American market. 

NAAAPI demanded in writing that X cigarettes 

be withdrawn. Extensive media coverage was given 

to NAAAPI leaders invited to speak, as part of Boston 

Black History Month events, to large audiences about 

the need for communities to mobilize against tobacco. 

As a result of NAAAPI’s organizing efforts, the creator and distributor of X cigarettes (Stowecroft Brook 

Distributors, Charlestown, Massachusetts) and the 

manufacturer (Star Tobacco Corporation, Petersburg, 

Virginia) received protests from around the country, 

including calls from organizations in the African 

296 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

American Tobacco Control Network of California. This 

successful strategy demonstrated again the effectiveness of united action against tobacco within the African American community and the ability of NAAAPI 

and its African American tobacco control network to 

extend the achievements of the Uptown experience. 

In other racial/ethnic communities, some groups 

have rejected billboards advertising tobacco products. 

In Detroit, for example, Wayne County Commissioner 

Alberta Tinsley-Williams founded the Coalition 

Against Billboard Advertising of Alcohol and Tobacco, 

which enlisted the support of churches, schools, and 

civic groups to seek the removal of such billboards. 

Other communities have gone even further. For 

example, inspired by the anonymous Chicagoan 

“Mandrake,” who painted over tobacco and alcohol 

billboards in ethnic neighborhoods, Reverend Calvin 

Butts led parishioners on walking tours in New York 

City to document and whitewash billboards advertising tobacco and alcohol (Associated Press 1990). Such 

acts were emulated by Dallas County, Texas, Commissioner John Wiley Price and Chicago-based Reverend 

Michael L. Phleger (Collins 1990). These grassroots 

efforts culminated in a meeting of African American 

community leaders in Greensboro, North Carolina, in 

1991. This meeting led to the founding of a national 

group to combat tobacco and alcohol advertising in 

ethnic communities, NAAAPI (Food & Drink Daily 

1991). Chaired by the Reverend Jesse W. Brown, the 

NAAAPI aims to increase public awareness of the devastating effects of cigarette and alcohol advertising 

among African Americans. The NAAAPI has gained 

affiliates in various communities throughout the 

United States. In 1994, the association supported efforts to drape covers over cigarette billboards in African American communities and led memorial services 

for persons who had died because of tobacco use. 

Another example of community mobilization 

against the advertising and promotion of tobacco products is taking place in California. To coordinate 

racial and ethnic-specific, state-funded activities supported by the increase in the cigarette sales tax, the 

California Department of Health Services’s Tobacco 

Control Section developed and funded four racial/ 

ethnic minority networks, the first of which was the 

Hispanic/Latino Tobacco Education Network. This 

network was hosted by the University of San Francisco through 1996 and has attracted more than 500 

members. The other networks include the Asian 

Pacific Islander Tobacco Education Network (initially 

hosted by the Asian American Health Forum), which 

comprises approximately 200 organizations; the African American Tobacco Education Network (initially 

sponsored by the Bay Area Urban League), which has 

approximately 300 members; and the American Indian 

Tobacco Education Network. These networks have 

been charged with coordinating and mobilizing tobacco control efforts among various communities and 

helping community agencies to better design and 

implement their programs. The various networks have 

different goals, responsibilities, and levels of funding, 

but one common thread is their commitment to ensuring that racial/ethnic communities take an active role 

in defining their own tobacco control needs. In general, the networks organize a variety of strategy and 

training sessions, media and advocacy campaigns, and 

technical assistance programs. They also help develop 

and evaluate resources on tobacco control and prevention and promote networking among their members. 

Although evaluations of these networks have not yet 

been completed, the networks’ role as catalysts is already evident. Thus far, the networks have garnered 

the support of community agencies funded to carry 

out tobacco control efforts in California. For example, 

70 percent of the funded community agencies in California reported attending meetings of these racial/ 

ethnic minority networks during the summer of 1993 

(Elder et al. 1993a). 

One emergent network is the International 

Multicultural Partnership, which grew out of the 

ASSIST program and provides technical assistance to 

racial/ethnic communities interested in tobacco prevention and control. It is a consortium that includes 

members from over 31 states and several countries. 

Its mission is to develop and implement culturally 

appropriate health education programs and services 

that will effectively reach those population groups at 

highest risk of tobacco-related illness and death. 

In addition to efforts to control tobacco advertising in specific racial/ethnic communities, the FDA 

regulations approved by President Clinton in August 

1996 broadly support such activities in racial/ethnic 

and other communities in the form of the provisions 

that ban billboards advertising tobacco products within 

1,000 feet of schools and playgrounds, limit in-store 

advertising (except in adult-only facilities) and billboards to black-and-white text, limit advertising to 

black-and-white text in publications with significant 

readership under age 18, prohibit brand logos on various promotional items, and prohibit sponsorship of 

sporting or entertainment events using brand or product identification. The FDA regulations are intended 

to reduce teenage access and attraction to tobacco products among all racial and racial/ethnic minority groups 

(Federal Register 1996). 

Tobacco Control and Education Efforts 297 
298 Chapter 5 

Surgeon General's Report 

Tobacco Product Regulations 

An important approach to controlling and preventing tobacco use is the drafting and enacting of 

product regulations. These large social interventions 

range from the use of cigarette warning labels to the 

licensing of tobacco product sales, and they can regulate the product’s packaging, its distribution, and even 

its components. Because most of these regulations affect all people residing in the United States, rather than 

just members of racial/ethnic communities, they are 

not described in detail here. The 1994 Youth Access 

Survey commissioned by RWJF found significant public support among all those surveyed for requiring 

tobacco companies to list the additives to their products on package labels (African Americans, 88.9 percent; Hispanics, 90.4 percent; and whites, 93.6 percent). 

Most respondents also supported government regulation of cigarettes, although support was somewhat 

stronger among Hispanics (81.1 percent) than among 

African Americans (72.6 percent) and whites (69.5 percent) (Table 11). 

Among the few tobacco product regulations to 

specifically target a racial/ethnic group are Spanishlanguage warning labels, which appear in cigarette advertisements and promotions in Spanish-language 

Table 11. Public beliefs about and support for policies related to nicotine and tobacco product regulation, 

Robert Wood Johnson Foundation Youth Access Survey, 1994 

African American* 

(N = 486) 

Hispanic 

(N = 402) 

White* 

(N = 1,341) 

Characteristic % ±CI† % ±CI % ±CI 

Think nicotine in cigarettes is addictive 90.9 2.90 86.8 4.16 92.6 1.65 

Believe that cigarette companies deliberately 

adjust nicotine levels to keep smokers 

addicted to cigarettes 57.5 5.41 56.8 5.62 54.9 3.06 

Favor requiring tobacco companies to gradually 

reduce the amount of nicotine in cigarettes 77.7 4.68 84.8 4.02 79.1 2.43 

Favor requiring insurance companies to cover 

the cost of programs to quit smoking 66.7 5.35 77.0 4.64 63.4 2.96 

Favor requiring tobacco companies to list 

additives on package labels the way food and 

drug companies are required to list 

ingredients 88.9 3.64 90.4 3.41 93.6 1.63 

Agree that because the government regulates 

all other products containing nicotine, such as 

nicotine patches and nicotine gum, the 

government should also regulate cigarettes 72.6 5.00 81.1 4.19 69.5 2.82 

*Non-Hispanic. 

†

95% confidence interval.
 

Source: Nancy Kaufman et al., unpublished data. Ethnic differences in public attitudes about policy alternatives
 

for limiting youth access to tobacco products: results of a national household survey, 1994.
 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

publications or on billboards located in Hispanic 

communities. The use of warning labels is one of the 

earliest and best known mechanisms that the federal 

government has employed to inform the public about 

the health hazards of smoking. Warning labels have 

been required on cigarette packages and in cigarette 

advertising since 1966, and four rotating health warnings have been required on cigarette packages and advertisements since October 12, 1984, through Public 

Law 98–474. Warning labels are not required on cigarettes made for export, cigarettes manufactured abroad 

by U.S. tobacco companies, or other tobacco products, 

such as cigars, pipe tobacco, and roll-your-own 

cigarette tobacco. Warning labels on smokeless tobacco 

containers have been required since passage in 1986 

of Public Law 99–252, which took effect in 1987. 

Little is known about the level of awareness or 

effectiveness of cigarette warning labels among 

members of racial/ethnic groups or members of the U.S. 

population at large. A 1991 study of Hispanics in San 

Conclusions 

Francisco has shown that Hispanics are more aware of 

the presence of warning labels on cigarettes (69.3 percent) than on other products, such as diet soda (27.2 

percent), wine (27.6 percent), beer (31.5 percent), and 

aspirin (36.7 percent) (Marín 1994). The same study also 

found that the level of awareness of cigarette warning 

labels was higher among highly acculturated Hispanics (76.5 percent) than among less acculturated Hispanics (65.5 percent). This finding may be attributable to 

the fact that highly acculturated Hispanics have greater 

fluency in English—the language used for most product warning labels and cigarette packages. 

Support for warning labels does not seem to differ significantly across racial/ethnic minority groups. 

In a 1992 Louis Harris and Associates poll of 488 smokers, 65 percent of Hispanics, 58 percent of African 

Americans, and 56 percent of whites favored legislation that required stronger warning labels on cigarette 

packages than those currently required by law (Louis 

Harris and Associates, unpublished data). 

1.	 More research is needed on the effect of culturally 

appropriate programs to reduce tobacco use 

among racial/ethnic minority groups. Interventions should be language appropriate; addressing 

psychosocial characteristics such as depression, 

stress, and acculturation may increase the acceptance of programs by members of racial/ethnic 

groups. 

2.	 To be culturally appropriate, tobacco control programs must reflect the targeted racial/ethnic 

group’s cultural values, consider the group’s 

psychosocial correlates of tobacco use, and use 

strategies that are acceptable and credible to members of the group. Culturally competent program 

staff must be aware and accepting of cultural differences, be able to assess their own cultural values, be conscious of intercultural dynamics when 

persons of different cultures interact, be aware of 

a racial/ethnic group’s relevant cultural characteristics, and have the skills to adapt to cultural 

diversity. 

3.	 Numerous strategies are needed to control tobacco 

use among racial/ethnic youths: restricting minors’ access to tobacco products, establishing culturally appropriate school-based programs, and 

designing mass media efforts geared to young 

people’s interests, attitudes, expectations, and 

norms. Recent provisions of the Synar Amendment, designed to prevent minors’ access to tobacco products, and the FDA regulations aimed 

at reducing the access to and appeal of tobacco 

products to young people are intended to reduce 

tobacco use among all youth, including members 

of racial/ethnic minority groups. 

4.	 Members of racial/ethnic groups are less likely 

than the general population to participate in smoking cessation groups and to receive cessation advice from health care providers. Barriers to ethnic 

group participation include limited cultural competence of health care providers and a lack of transportation, money, and access to health care. 

Tobacco Control and Education Efforts 299 
 

Surgeon General's Report 

5.	 Available data indicate that racial/ethnic groups 

support smoking restrictions, such as increasing 

cigarette excise taxes, banning cigarette advertisements, restricting access to cigarette vending machines, raising the legal age of purchase, 

prohibiting sponsorship of events by tobacco companies, and establishing clean indoor air regulations. Additional research is needed to evaluate 

how best to build on this base of public opinion 

support to strengthen existing tobacco prevention 

and control programs within racial/ethnic 

communities. 

6.	 Prevention and cessation efforts in racial/ethnic 

communities are limited by underdeveloped tobacco control infrastructures and low levels of resources for research, program development, and 

program dissemination. Greater resources are 

needed in racial/ethnic minority communities to 

build tobacco control infrastructures and to 

develop initiatives. 

300 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

References 

Aday LA, Lee ES, Spears B, Chung C-W, Youssef A, 

Bloom B. Health insurance and utilization of medical 

care for children with special health care needs. Medical Care 1993;31(11):1013–26. 

Ahluwalia JS, McNagny SE. Smoking prevalence and 

desire to quit in inner-city African American walk-in 

clinic patients. Clinical Research 1993;41(4):752A. 

Alcalay R, Ghee A, Scrimshaw S. Designing prenatal 

care messages for low-income Mexican women. Public Health Reports 1993;108(3):354–62. 

Allen KF, Moss AJ, Giovino GA, Shopland DR, Pierce 

JP. Teenage tobacco use: data estimates from the Teenage Attitudes and Practices Survey, United States, 1989. 

Advance Data. No. 224. Washington (DC): US Department of Health and Human Services, Public Health 

Service, Centers for Disease Control and Prevention, 

National Center for Health Statistics. DHHS Publication No. (PHS) 93-1250, 1993. 

Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of cigarettes to minors. Journal 

of the American Medical Association 1989;261(1):80–8. 

American Indian Cancer Control Project. It’s Your Life— 

It’s Our Future [stop smoking guide and video]. Berkeley (CA): American Indian Cancer Control Project, 1991. 

American Lung Association. Don’t Let Your Dreams Go 

Up in Smoke [brochure]. West Babylon (NY): American 

Lung Association, 1990a. 

American Lung Association. Stop Before You Drop [videotape]. Richmond (CA): Richmond Quits Smoking 

Project, 1990b. 

Amezcua C, McAlister A, Ramirez A, Espinoza R. A 

Su Salud: health promotion in a Mexican-American 

border community. In: Bracht N, editor. Health Promotion at the Community Level. Newbury Park (CA): Sage 

Publications, 1990:257–77. 

Associated Press. Billboard vigilante targets minority 

area. The Houston Post 1990 Jan 26;Sect A:7 (col 1). 

Bandura A. Social Learning Theory. Englewood Cliffs 

(NJ): Prentice-Hall, 1977. 

Bayer R. AIDS prevention and cultural sensitivity: are 

they compatible? American Journal of Public Health 

1994;84(6):895–8. 

Bloom B, Gift HC, Jack SS. Dental services and oral 

health: United States, 1989. Vital and Health Statistics. 

Series 10, No. 183. Hyattsville (MD): US Department 

of Health and Human Services, Public Health Service, 

Centers for Disease Control and Prevention, National 

Center for Health Statistics. DHHS Publication No. 

(PHS) 93-1511, 1992. 

Blosser BJ. Ethnic differences in children’s media use. 

Journal of Broadcasting and Electronic Media 1988;32 

(4):453–70. 

Botvin GJ, Batson HW, Witts-Vitale S, Bess V, Baker E, 

Dusenbury L. A psychosocial approach to smoking 

prevention for urban black youth. Public Health Reports 

1989a;104(6):573–82. 

Botvin GJ, Dusenbury L, Baker E, James-Ortiz S, Botvin EM, 

Kerner J. Smoking prevention among urban minority 

youth: assessing effects on outcome and mediating 

variables. Health Psychology 1992;11(5):290–9. 

Botvin GJ, Dusenbury L, Baker E, James-Ortiz S, Kerner J. 

A skills training approach to smoking prevention 

among Hispanic youth. Journal of Behavioral Medicine 

1989b;12(3):279–96. 

Breslow L, Johnson M. California’s Proposition 99 on 

tobacco, and its impact. Annual Review of Public Health 

1993;14:585–604. 

Brownson RC, Jackson-Thompson J, Wilkerson JC, 

Davis JR, Owens NW, Fisher EB Jr. Demographic and 

socioeconomic differences in beliefs about the health 

effects of smoking. American Journal of Public Health 

1992;82(1):99–103. 

Bruerd B, Grimm J, Mead S, Schlife C, Jones D, Tucker J, 

et al. The Alaska Native Community-Oriented Tobacco 

Project Evaluation Report. Anchorage (AK): Prevention 

Associates, September 1994. 

Tobacco Control and Education Efforts 301 
 

Surgeon General's Report 

Bulterys M, Morgenstern H, Welty TK, Kraus JF. The 

expected impact of a smoking cessation program for 

pregnant women on infant mortality among Native 

Americans. American Journal of Preventive Medicine 

1990;6(5):267–73. 

Burhansstipanov L, Dresser C. Documentation of the 

Cancer Research Needs of American Indians and Alaska 

Natives. Native American Monograph No. 1. Bethesda 

(MD): US Department of Health and Human Services, 

Public Health Service, National Institutes of Health, 

National Cancer Institute, Division of Cancer Prevention and Control, Cancer Control Science Program. 

NIH Publication No. 93-3603, 1993. 

Burns D, Pierce JP. Tobacco Use in California, 1990–1991. 

Sacramento (CA): California Department of Health 

Services, 1992. 

California Department of Health Services, Tobacco 

Control Section. It’s No Joke, Don’t Smoke! [videotape]. 

Los Angeles: KCET/Educational Enterprises and 

Sueno Productions, 1993. 

Campbell KM, Kaplan CP. Relationship between language orientation and cigarette-smoking beliefs of 

Latinas. American Journal of Health Behavior 1997; 

21(1):12–20. 

Cella DF, Tulsky DS, Sarafian B, Thomas CR Jr, Thomas CR Sr. Culturally relevant smoking prevention for 

minority youth. Journal of School Health 1992;62 

(8):377–80. 

Centers for Disease Control and Prevention. The Great 

American Smokeout—November 19, 1992. Morbidity 

and Mortality Weekly Report 1992;41(45):853. 

Centers for Disease Control and Prevention. Physician 

and other health-care professional counseling of smokers to quit—United States, 1991. Morbidity and Mortality Weekly Report 1993a;42(44):854–7. 

Centers for Disease Control and Prevention. Smoking 

cessation during previous year among adults—United 

States, 1990 and 1991. Morbidity and Mortality Weekly 

Report 1993b;42(26):504–7. 

Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco 

use and addiction. Morbidity and Mortality Weekly Report 1994;43(RR-2):1–18. 

Centers for Disease Control and Prevention. Accessibility of tobacco products to youths aged 12–17 years— 

United States, 1989 and 1993. Morbidity and Mortality 

Weekly Report 1996;45(6):125–30. 

Cernada GP, Darity WA, Chen TTL, Winder AE, Benn S, 

Jackson R, et al. Mass media usage among black smokers: a first look. International Quarterly of Community 

Health Education 1989–1990;10(4):347–64. 

Chen MS Jr, Guthrie R, Anderson J, Kuun P, 

Moeschberger M, Zaharlick A. An evaluation of heart 

health education for Southeast Asians. American Journal of Preventive Medicine 1994;10(4):205–8. 

Chen MS Jr, Guthrie R, Moeschberger M, Wewers ME, 

Anderson J, Kuun P, et al. Lessons learned and baseline 

data from initiating smoking cessation research with 

Southeast Asian adults. Asian American and Pacific Islander Journal of Health 1993;1(2):194–214. 

Chinese Community Smoke-Free Project. Victory Over 

Smoking: A Guide to Smoking Cessation for You and Your 

Family. San Francisco: Chinese Community SmokeFree Project, 1992. 

Collins J. Billboard folks cite rights; foes say ads wrong. 

Dallas Times Herald 1990 Mar 21;Sect A:1 (col 1). 

Corcoran RD, Robinson RG. Community demonstration project initiative: technical support for program 

development at the community level. Cancer Practice 

1994;2(3):222–8. 

Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a 

Culturally Competent System of Care,Volume 1. Washington (DC): Georgetown University Child Development 

Center, Child and Adolescent Service System Program 

Technical Assistance Center, 1989. 

Cunningham-Sabo L, Davis SM. Pathways to Health: 

a health promotion and cancer prevention project for 

American Indian youth. Alaska Medicine 1993; 

35(4):275–8, 296. 

Davis RM. Reducing youth access to tobacco. Journal of 

the American Medical Association 1991;266(22):3186–8. 

Davis S, Lambert LC, Cunningham-Sabo L, Skipper BJ. 

Tobacco use: baseline results from Pathways to Health, 

a school-based project for southwestern American 

Indian youth. Preventive Medicine 1995a;24(5): 454–60. 

302 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Davis SM, Lambert LC, Gomez Y, Skipper BJ. Southwest Cardiovascular Curriculum Project: study 

findings for American Indian elementary students. 

Journal of Health Education 1995b;26(2):S72–S81. 

Davis BJ, Voegtle KH. Culturally Competent Health Care 

for Adolescents: A Guide for Primary Care Providers. Chicago: American Medical Association, Department of 

Adolescent Health, 1994. 

DiFranza JR, Brown LJ. The Tobacco Institute’s “It’s 

the Law” campaign: has it halted illegal sales of tobacco to children? American Journal of Public Health 

1992;82(9):1271–3. 

DiFranza JR, Savageau JA, Aisquith BF. Youth access 

to tobacco: the effects of age, gender, vending machine 

locks, and “It’s the Law” programs. American Journal 

of Public Health 1996;86(2):221–4. 

Dusenbury L, Botvin GJ. Substance abuse prevention: 

competence enhancement and the development of 

positive life options. Journal of Addictive Diseases 

1992;11(3):29–45. 

Edwards NC, MacMillan K. Tobacco use and ethnicity: 

the existing data gap. Canadian Journal of Public Health 

1990;81(Jan-Feb):32–6. 

Elder JP, Edwards C, Conway TL. Independent Evaluation of Proposition 99-Funded Efforts to Prevent and 

Control Tobacco Use in California [annual report]. 

Submitted to California Department of Health Services, Tobacco Control Section. San Diego (CA): San 

Diego State University, Graduate School of Public 

Health, 1993a. 

Elder JP, Edwards CC, Conway TL, Kenney E, Johnson CA, 

Bennett ED. Independent evaluation of the California 

tobacco education program. Public Health Reports 

1996;111(4):353–8. 

Elder JP, Wildey M, de Moor C, Sallis JF, Eckhardt L, 

Edwards C, et al. The long-term prevention of tobacco 

use among junior high school students: classroom and 

telephone interventions. American Journal of Public 

Health 1993b;83(9):1239–44. 

Ellis GA, Reed DF, Scheider H. Mobilizing a lowincome African American community around tobacco 

control: a force field analysis. Health Education Quarterly 1995;22(4):443–57. 

Ewert D, Alleyne D. Risk of exposure to outdoor advertising of cigarettes and alcohol [letter]. American 

Journal of Public Health 1992;82(6):895–6. 

Farquhar JW, Fortmann SP, Flora JA, Taylor CB, Haskell WL, 

Williams PT, et al. Effects of community-wide education on cardiovascular disease risk factors: the Stanford 

Five-City Project. Journal of the American Medical Association 1990;264(3):359–65. 

Farquhar JW, Fortmann SP, Maccoby N, Haskell WL, 

Williams PT, Flora JA, et al. The Stanford Five-City 

Project: design and methods. American Journal of Epidemiology 1985;122(2):323–34. 

Federal Register. US Department of Health and Human 

Services, Food and Drug Administration. Regulations 

restricting the sale and distribution of cigarettes and 

smokeless tobacco to protect children and adolescents; 

final rule (21 CFR Parts 801, 803, 804, 807, 820, and 

897), 61 Federal Register 44396 (1996). 

Federal Trade Commission. Report to Congress: Pursuant to the Federal Cigarette Labeling and Advertising Act. 

Washington (DC): Federal Trade Commission, 1997. 

Feighery E, Altman DG, Shaffer G. The effects of combining education and enforcement to reduce tobacco 

sales to minors: a study of four northern California 

communities. Journal of the American Medical Association 1991;266(22):3168–71. 

Fiore MC, Novotny TE, Pierce JP, Giovino GA, 

Hatziandreu EJ, Newcomb PA, et al. Methods used to 

quit smoking in the United States: do cessation programs help? Journal of the American Medical Association 1990;263(20):2760–5. 

Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, 

Gritz ER, et al. Smoking Cessation. Clinical Practice Guideline No. 18. Rockville (MD): US Department of Health 

and Human Services, Public Health Service, Agency 

for Health Care Policy and Research. AHCPR Publication No. 96-0692, 1996. 

Flay BR, Ockene JK, Tager IB. Smoking: epidemiology, 

cessation, and prevention. Chest 1992;102(3):277S–301S. 

Food & Drink Daily. Black-led group targets alcohol and 

tobacco ads. Food & Drink Daily 1991;1(8):3. 

Forster JL, Hourigan M, McGovern P. Availability of 

cigarettes to underage youth in three communities. 

Preventive Medicine 1992;21(3):320–8. 

Tobacco Control and Education Efforts 303 
 

Surgeon General's Report 

Fortmann SP, Taylor CB, Flora JA, Jatulis DE. Changes 

in adult cigarette smoking prevalence after 5 years of 

community health education: the Stanford Five-City 

Project. American Journal of Epidemiology 1993; 

137(1):82–96. 

Frank E, Winkleby MA, Altman DG, Rockhill B, 

Fortmann SP. Predictors of physicians’ smoking cessation advice. Journal of the American Medical Association 1991;266(22):3139–44. 

Gerlach KK, Shopland DR, Hartman AM, Gibson JT, 

Pechacek TF. Workplace smoking policies in the United 

States: results from a national survey of more than 

100,000 workers. Tobacco Control 1997;6(3):199–206. 

Glasgow RE, Lichtenstein E, Wilder D, Hall R, McRae SG, 

Liberty B. The Tribal Tobacco Policy Project: working 

with northwest Indian tribes on smoking policies. Preventive Medicine 1995;24(5):434–40. 

Glynn TJ. Essential elements of school-based smoking 

prevention programs. Journal of School Health 1989; 

59(5):181–8. 

Glynn TJ, Anderson DM, Schwarz L. Tobacco-use 

reduction among high-risk youth: recommendations 

of a National Cancer Institute Expert Advisory Panel. 

Preventive Medicine 1991;20(2):279–91. 

Glynn TJ, Boyd GM, Gruman JC. Self-Guided Strategies 

for Smoking Cessation: A Program Planner’s Guide. Washington (DC): US Department of Health and Human 

Services, Public Health Service, National Institutes of 

Health, National Cancer Institute, Smoking and Tobacco 

Control Program. NIH Publication No. 91-3104, 1990. 

Glynn TJ, Manley MW. How To Help Your Patients Stop 

Smoking: A National Cancer Institute Manual for Physicians. Washington (DC): US Department of Health and 

Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, Division of 

Cancer Prevention and Control, Smoking and Tobacco 

Control Program. NIH Publication No. 92-3064, 1992. 

Gonzalez VM, Gonzalez JT, Freeman V, Howard-Pitney B. 

Health Promotion in Diverse Cultural Communities. Palo 

Alto (CA): Health Promotion Resource Center, 

Stanford Center for Research in Disease Prevention, 

1991. 

Graham JW, Johnson CA, Hansen WB, Flay BR, Gee M. 

Drug use prevention programs, gender, and ethnicity: 

evaluation of three seventh-grade Project SMART cohorts. Preventive Medicine 1990;19(3):305–13. 

Grossman M. Health benefits of increases in alcohol 

and cigarette taxes. British Journal of Addiction 1989; 

84(10):1193–1204. 

Hahn LP, Folsom AR, Sprafka JM, Norsted SW. Cigarette smoking and cessation behaviors among urban 

blacks and whites. Public Health Reports 1990;105 

(3):290–5. 

Hall RA, Lichtenstein E, Burhansstipanov L, Davis SM, 

Hodge F, Schinke S, et al. Tobacco use policies and practices in diverse Indian settings. American Indian Culture and Research Journal 1995;19(3):165–80. 

Health and Public Policy Committee, American College 

of Physicians. Methods for stopping cigarette smoking. 

Annals of Internal Medicine 1986;105(2):281–91. 

Hodge FS, Cummings S, Fredericks L, Kipnis P, 

Williams M, Teehee K. Prevalence of smoking among 

adult American Indian clinic users in northern California. Preventive Medicine 1995;24(5):441–6. 

Hodge FS, Fredericks L, Kipnis P. Patient and smoking patterns in northern California American Indian 

clinics. Urban and rural contrasts. Cancer 1996;78(7 

Suppl):1623–8. 

Hofstede G. Culture’s Consequences: International Differences in Work-Related Values. Beverly Hills (CA): Sage 

Publications, 1980. 

Hopkins RS. Insurance coverage and usage of preventive health services. Journal of the Florida Medical Association 1993;80(8):529–32. 

Hymowitz N, Jackson J, Carter R, Eckholdt H. Past quit 

smoking assistance and doctors’ advice for white and 

African-American smokers. Journal of the National Medical Association 1996;88(4):249–52. 

Jackson C, Flora JA, Winkleby MA, Fortmann SP. Use 

of educational resources for cardiovascular risk reduction in the Stanford Five-City Project. American Journal of Preventive Medicine 1991;7(2):82–8. 

Jackson DZ. Making money by any means necessary. 

Boston Globe 1995 Feb 1;Sect OP-ED:13. 

304 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Jason LA, Billows WD, Schnopp-Wyatt DL, King C. 

Long-term findings from Woodridge in reducing illegal cigarette sales to older minors. Evaluation and the 

Health Professions 1996;19(1):3–13 

Jason LA, Ji PY, Anes MD, Birkhead SH. Active enforcement of cigarette control laws in the prevention 

of cigarette sales to minors. Journal of the American 

Medical Association 1991;266(22):3159–61. 

Jason LA, Tait E, Goodman D, Buckenberger L, Gruder 

CL. Effects of a televised smoking cessation intervention among low-income and minority smokers. American Journal of Community Psychology 1988;16(6):863–76. 

Jenkins CNH, McPhee SJ, Bird JA, Bonilla N-TH. Cancer risks and prevention practices among Vietnamese 

refugees. Western Journal of Medicine 1990;153(1):34–9. 

Jenkins CNH, McPhee SJ, Le A, Pham GQ, Ha N-T, 

Stewart S. The effectiveness of a media-led intervention to reduce smoking among Vietnamese-American 

men. American Journal of Public Health 1997;87 

(6):1031–4. 

Jung C. Smoking dies hard in Asian businesses: Santa 

Clara County cuts tobacco control funding. San Jose 

Mercury News 1993 July 6;Sect B:1. 

Kaplan RM, Pierce JP, Gilpin EA, Johnson M, Bal DG. 

Stages of smoking cessation: the 1990 California Tobacco Survey. Tobacco Control 1993;2(2):139–44. 

Keay KD, Woodruff SI, Wildey MB, Kenney EM. Effect of a retailer intervention on cigarette sales to minors in San Diego County, California. Tobacco Control 

1993;2(2):145–51. 

Keeler TE, Hu T-W, Barnett PG, Manning WG. Taxation, regulation, and addiction: a demand function for 

cigarettes based on time-series evidence. Journal of 

Health Economics 1993;12(1):1–18. 

Klonoff EA, Fritz JM, Landrine H, Riddle RW, TullyPayne L. The problem and sociocultural context of 

single-cigarette sales. Journal of the American Medical 

Association 1994;271(8):618–20. 

Klonoff EA, Landrine H, Alcaraz R. An experimental 

analysis of sociocultural variables in sales of cigarettes 

to minors. American Journal of Public Health 1997; 

87(5):823–6. 

Kogan MD, Kotelchuck M, Alexander GR, Johnson WE. 

Racial disparities in reported prenatal care advice from 

health care providers. American Journal of Public Health 

1994;84(1):82–8. 

Kottke TE, Willms DG, Solberg LI, Brekke ML. Physician-delivered smoking cessation advice: issues identified during ethnographic interviews. Tobacco Control 

1994;3(1):46–9. 

Lacey LP, Manfredi C, Balch G, Warnecke RB, Allen K, 

Edwards C. Social support in smoking cessation 

among black women in Chicago public housing. Public Health Reports 1993;108(3):387–94. 

Lacey L, Tukes S, Manfredi C, Warnecke RB. Use of 

lay health educators for smoking cessation in a hardto-reach urban community. Journal of Community Health 

1991;16(5):269–82. 

Lando HA, Johnson KM, Graham-Tomasi RP, 

McGovern PG, Solberg L. Urban Indians’ smoking 

patterns and interest in quitting. Public Health Reports 

1992;107(3):340–4. 

Landrine H, Klonoff EA, Fritz JM. Preventing cigarette 

sales to minors: the need for contextual, sociocultural 

analysis. Preventive Medicine 1994;23(3):322–7. 

Landrine H, Klonoff EA, Alcaraz R. Racial discrimination in minors’ access to tobacco. Journal of Black 

Psychology 1997;23(2):135–47. 

Lichtenstein E, Glasgow RE. Smoking cessation: what 

have we learned over the past decade? Journal of Consulting and Clinical Psychology 1992;60(4):518–27. 

Lichtenstein E, Glasgow RE, Lopez K, Hall R, McRae SG, 

Meyers GB. Promoting tobacco control policies in 

Northwest Indian tribes. American Journal of Public 

Health 1995;85(7):991–4. 

Lieberman Research Inc. Non-Whites’ Participation in 

the 1993 Great American Smokeout. New York: 

Lieberman Research Inc., conducted for the American 

Cancer Society, 1993. 

Lieu TA, Newacheck PW, McManus MA. Race, 

ethnicity, and access to ambulatory care among US 

adolescents. American Journal of Public Health 1993; 

83(7):960–5. 

Tobacco Control and Education Efforts 305 
 

Surgeon General's Report 

Lynch BS, Bonnie RJ, editors. Growing Up Tobacco Free: 

Preventing Nicotine Addiction in Children and Youths. 

Washington (DC): National Academy Press, 1994. 

Manfredi C, Lacey L, Warnecke R, Buis M. Smokingrelated behavior, beliefs, and social environment of 

young Black women in subsidized public housing in 

Chicago. American Journal of Public Health 1992;82(2): 

267–72. 

Marín G. Defining culturally appropriate community 

interventions: Hispanics as a case study. Journal of Community Psychology 1993;21(2):149–61. 

Marín G. Self-reported awareness of the presence of 

product warning messages and signs by Hispanics in 

San Francisco. Public Health Reports 1994;109(2):275–83. 

Marín G. Perceptions by Hispanics of channels and 

sources of health messages regarding cigarette smoking. Tobacco Control 1996;5(1):30–6. 

Marín G, Marín BV, Otero-Sabogal R, Sabogal F, PérezStable EJ. The role of acculturation in the attitudes, 

norms, and expectancies of Hispanic smokers. Journal 

of Cross-Cultural Psychology 1989;20(4):399–415. 

Marín BV, Marín G, Pérez-Stable EJ, Hauck WW. Effects of a community intervention to change smoking 

behavior among Hispanics. American Journal of Preventive Medicine 1994;10(6):340–7. 

Marín BV, Marín G, Pérez-Stable EJ, Otero-Sabogal R, 

Sabogal F. Cultural differences in attitudes toward 

smoking: developing messages using the theory of 

reasoned action. Journal of Applied Social Psychology 

1990a;20(6):478–93. 

Marín G, Marín BV, Pérez-Stable EJ, Sabogal F, OteroSabogal R. Changes in information as a function of a 

culturally appropriate smoking cessation community 

intervention for Hispanics. American Journal of Community Psychology 1990b;18(6):847–64. 

Marín G, Marín BV, Pérez-Stable EJ, Sabogal F, OteroSabogal R. Cultural differences in attitudes and expectancies between Hispanic and non-Hispanic white 

smokers. Hispanic Journal of Behavioral Sciences 

1990c;12(4):422–36. 

Marín G, Pérez-Stable EJ. Effectiveness of disseminating culturally appropriate smoking-cessation information: Programa Latino Para Dejar de Fumar. Journal of 

the National Cancer Institute Monographs 1995;18:155–63. 

Marttila & Kiley, Inc. Highlights from an American Cancer Society Survey of U.S. Voter Attitudes Toward Cigarette Smoking. Boston: Marttila & Kiley, Inc., 1993. 

McAlister A, Puska P, Salonen JT, Tuomilehto J, Koskela 

K. Theory and action for health promotion: illustrations from the North Karelia Project. American Journal 

of Public Health 1982;72(1):43–50. 

McAlister AL, Ramirez AG, Amezcua C, Pulley L, Stern 

MP, Mercado S. Smoking cessation in Texas-Mexico 

border communities: a quasi-experimental panel study. 

American Journal of Health Promotion 1992;6(4):274–9. 

McPhee SJ, Jenkins CNH, Anh L. Smoking Prevention 

and Cessation Among Vietnamese in Northern California: 

Final Report. Sacramento (CA): Report submitted to the 

Tobacco Control Section, Department of Health Services, State of California, 1993. 

McPhee SJ, Jenkins CNH, Wong C, Fordham D, Lai KQ, 

Bird JA, Moskowitz JM. Smoking cessation intervention among Vietnamese Americans: a controlled trial. 

Tobacco Control 1995;4(1 Suppl):16S–24S. 

Moncher M, Schinke S. Group intervention to prevent 

tobacco use among Native American youth. Research 

on Social Work Practice 1994;4(2):160–71. 

National Cancer Institute. Strategies to Control Tobacco 

Use in the United States: A Blueprint for Public Health 

Action in the 1990’s. Smoking and Tobacco Control 

Monograph No. 1. Bethesda (MD): US Department of 

Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute. NIH Publication No. 92-3316, 1991. 

National Cancer Institute. Datos Sobre el Hábito de Fumar 

y Recomendaciones Para Dejar de Fumar (Smoking: Facts 

and Quitting Tips for Hispanics). Washington (DC): US 

Department of Health and Human Services, Public 

Health Service, National Institutes of Health, National 

Cancer Institute. NIH Publication No. 92-3405S, 1992a. 

National Cancer Institute. Smoking: Facts and Quitting 

Tips for Black Americans. Washington (DC): US Department of Health and Human Services, Public Health 

Service, National Institutes of Health, National Cancer Institute. NIH Publication No. 92-3405, 1992b. 

306 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

National Cancer Institute. Tobacco and the Clinician: Interventions for Medical and Dental Practice. Washington 

(DC): US Department of Health and Human Services, 

Public Health Service, National Institutes of Health, 

National Cancer Institute. NIH Publication No. 94­

3693, 1994. 

National High Blood Pressure Education Program. 

Churches as an Avenue to High Blood Pressure Control. 

Washington (DC): US Department of Health and 

Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood 

Institute, National High Blood Pressure Education 

Program. NIH Publication No. 92-2725, 1992. 

Nestle M, Cowell C. Health promotion for low-income 

minority groups: the challenge for nutrition education. 

Health Education Research: Theory & Practice 1990; 

5(4):527–33. 

Nevid JS, Javier RA. “Si, puedo” smoking cessation 

program for Hispanic smokers. Paper presented at the 

Fourth National Forum on Cardiovascular Health, 

Pulmonary Disorders, and Blood Resources, Minority 

Health Issues for an Emerging Majority, Washington, 

DC, June 1992. 

O’Campo P, Faden RR, Brown H, Gielen AC. The impact of pregnancy on women’s prenatal and postpartum smoking behavior. American Journal of Preventive 

Medicine 1992;8(1):8–13. 

O’Connor C, editor. State Legislated Actions on Tobacco 

Issues. Washington (DC): The Coalition on Smoking 

OR Health, 1992. 

Orlandi MA, editor. Cultural Competence for Evaluators: 

A Guide for Alcohol and Other Drug Abuse Prevention 

Practitioners Working With Ethnic/Racial Communities. 

Office for Substance Abuse Prevention Cultural Competence Series 1. Rockville (MD): US Department of 

Health and Human Services, Public Health Service, 

Alcohol, Drug Abuse, and Mental Health Administration, Office for Substance Abuse Prevention, Division 

of Community Prevention and Training. DHHS Publication No. (ADM) 92-1884, 1992. 

Orleans CT, Schoenbach VJ, Salmon MA, Strecher VJ, 

Kalsbeek W, Quade D, et al. A survey of smoking and 

quitting patterns among black Americans. American 

Journal of Public Health 1989;79(2):176–81. 

Otero-Sabogal R, Sabogal F. La Mujer: La Familia y el 

Cigarrillo. San Francisco: American Lung Association 

of San Francisco, 1991. 

Pérez-Stable EJ, Marín BV, Marín G. A comprehensive 

smoking cessation program for the San Francisco Bay 

Area Latino Community: Programa Latino Para Dejar 

de Fumar. American Journal of Health Promotion 1993; 

7(6):430–42, 475. 

Pérez-Stable EJ, Marín G, Marín BV. Behavioral risk 

factors: a comparison of Latinos and non-Latino whites 

in San Francisco. American Journal of Public Health 

1994;84(6):971–6. 

Pérez-Stable EJ, Sabogal F, Marín G, Marín BV, OteroSabogal R. Evaluation of “Guía Para Dejar de Fumar,” 

a self-help guide in Spanish to quit smoking. Public 

Health Reports 1991;106(5):564–70. 

Pérez-Stable EJ, Sabogal F, Otero-Sabogal R, Hiatt RA, 

McPhee SJ. Misconceptions about cancer among 

Latinos and Anglos. Journal of the American Medical 

Association 1992;288(22):3219–23. 

Perry CL, Murray DM, Griffin G. Evaluating the statewide dissemination of smoking prevention curricula: 

factors in teacher compliance. Journal of School Health 

1990;60(10):501–4. 

Peterson DE, Zeger SL, Remington PL, Anderson HA. 

The effect of state cigarette tax increases on cigarette 

sales, 1955 to 1988. American Journal of Public Health 

1992;82(1):94–6. 

Pierce JP, Cavin SW, Macky C, Rosbrook B, Berry CC, 

Maklan DM, et al. Technical Report on Analytic Methods 

and Approaches Used in the 1992 California Tobacco Survey Analysis. Sacramento (CA): California Department 

of Health Services, 1994a. 

Pierce JP, Evans N, Farkas AJ, Cavin SW, Berry C, 

Kramer M, et al. Tobacco Use in California: An Evaluation of the Tobacco Control Program, 1989–1993. La Jolla 

(CA): University of California, San Diego, 1994b. 

Pierce JP, Fiore MC, Novotny TE, Hatziandreu EJ, 

Davis RM. Trends in cigarette smoking in the United 

States: projections to the year 2000. Journal of the American Medical Association 1989;261(1):61–5. 

Tobacco Control and Education Efforts 307 
 

Surgeon General's Report 

Pletsch PK. Environmental tobacco smoke exposure 

among Hispanic women of reproductive age. Public 

Health Nursing 1994;11(4):229–35. 

Prochaska JO. A transtheoretical model of behavior 

change: learning from mistakes with majority populations. In: Becker DM, Hill DR, Jackson JS, Levine DM, 

Stillman FA, Weiss SM, editors. Health Behavior Research 

in Minority Populations: Access, Design, and Implementation. Washington (DC): US Department of Health and 

Human Services, Public Health Service, National Institutes of Health. NIH Publication No. 92-2965, 

1992:105. 

Programa Latino Para Dejar de Fumar de San Francisco. El Fumar un Juego Peligroso . . . Guía Para Dejar de 

Fumar. San Francisco: Programa Latino Para Dejar de 

Fumar de San Francisco, 1992. 

Programa Latino Para Dejar de Fumar de San Francisco. Rompa Con el Vicio: Una Guía Para Dejar de Fumar. 

Washington (DC): US Department of Health and 

Human Services, Public Health Service, National 

Institutes of Health, National Cancer Institute. NIH 

Publication No. 94-3001, 1993. 

Puska P, McAlister A, Niemensivu H, Piha T, Wiio J, 

Koskela K. A television format for national health promotion: Finland’s “Keys to Health.” Public Health Reports 1987;102(3):263–9. 

Ramirez AG, McAlister AL. Mass media campaign— 

A Su Salud. Preventive Medicine 1988;17(5):608–21. 

Reid DJ, Killoran AJ, McNeill AD, Chambers JS. Choosing the most effective health promotion options for 

reducing a nation’s smoking prevalence. Tobacco Control 1992;3(1):185–97. 

Rigotti NA, Pashos CL. No-smoking laws in the United 

States. Journal of the American Medical Association 

1991;266(22):3162–7. 

Roberts RN. Developing Culturally Competent Programs 

for Families of Children with Special Needs. 2nd ed. 

Washington (DC): Georgetown University Child Development Center and the Maternal and Child Health 

Bureau, 1990. 

Robinson RG, Kessler LG, Naughton MD. Cancer 

awareness among African Americans: a survey assessing race, social status, and occupation. Journal of the 

National Medical Association 1991;83(6):491–7. 

Robinson RG, Orleans CT, James DA, Sutton CD. Pathways to Freedom: Winning the Fight Against Tobacco. 

Philadelphia: Fox Chase Cancer Center, 1992. Reprinted with permission by the Centers for Disease 

Control and Prevention and the National Medical Association. 

Robinson RG, Shelton DM, Hodge F, Lew R, Lopez E, 

Toy P, et al. Tobacco control capacity index for communities of color in the United States. In: Slama K, 

editor. Tobacco and Health. New York: Plenum Press, 

1995:359–65. 

Robinson RG, Sutton CD. The Coalition Against Uptown Cigarettes. In: Jernigan D, Wright PA, editors. 

Making News, Changing Policy. Washington (DC): US 

Office of Personnel Management, Center for Substance 

Abuse Prevention, and The Marin Institute for the Prevention of Alcohol and Other Drug Problems, in press. 

Rogler LH, Malgady RG, Costantino G, Blumenthal R. 

What do culturally sensitive mental health services 

mean? the case of Hispanics. American Psychologist 

1987;42(6):565–70. 

Roper Center for Public Opinion Research. Attitudes 

on Smoking by Race. Telephone Survey Conducted from 

February 25 to 28, 1993. Storrs (CT): Roper Center for 

Public Opinion Research, University of Connecticut, 

conducted by ABC News/The Washington Post, 1993. 

Royce JM, Ashford A, Resnicow K, Freeman HP, Caesar AA, Orlandi MA. Physician- and nurse-assisted 

smoking cessation in Harlem. Journal of the National 

Medical Association 1995;87(4):291–300. 

Royce JM, Hymowitz N, Corbett K, Hartwell TD, 

Orlandi MA. Smoking cessation factors among African Americans and Whites. American Journal of Public 

Health 1993;83(2):220–6. 

Sabogal F, Marín B, Marín G, Otero-Sabogal R, PérezStable EJ. Guía Para Dejar de Fumar: Por Su Salud y Su 

Familia. Washington (DC): US Department of Health 

and Human Services, Public Health Service, National 

Institutes of Health, National Cancer Institute. NIH 

Publication No. 88-3001, 1988. 

Sabogal F, Marín G, Otero-Sabogal R, Marín BV, PérezStable EJ. Hispanic familism and acculturation: what 

changes and what doesn’t? Hispanic Journal of Behavioral Sciences 1987;9(4):397–412. 

308 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Sallis JF, Elder JP, Wildey MB, de Moor C, Young RL, 

Shulkin JL, et al. Assessing skills for refusing cigarettes 

and smokeless tobacco. Journal of Behavioral Medicine 

1990;13(5):489–503. 

Satcher D, Eriksen M. The paradox of tobacco control 

[editorial]. Journal of the American Medical Association 

1994;271(8):627–8. 

Satcher D, Robinson RG. The CDC and the NMApartnerships to control tobacco in the AfricanAmerican community. Journal of the National Medical 

Association 1994;86(7):493–6. 

Schinke SP, Moncher MS, Singer BR. Native American 

youths and cancer risk reduction: effects of software 

intervention. Journal of Adolescent Health 1994; 

15(2):105–10. 

Schinke SP, Orlandi MA, Botvin GJ, Gilchrist LD, 

Trimble JE, Locklear VS. Preventing substance abuse 

among American-Indian adolescents: a bicultural competence skills approach. Journal of Counseling Psychology 1988;35(1):87–90. 

Schinke SP, Singer B, Cole K, Contento IR. Reducing 

cancer risk among Native-American adolescents. Preventive Medicine 1996;25(2):146–55. 

Schoenbach VJ, Orleans CT, Salmon MA, Quade D, 

Strecher VJ, Kalsbeek WD, et al. A self-help quit smoking program for black Americans. Paper presented at 

the 116th Annual Meeting of the American Public 

Health Association, Boston, November 16, 1988. 

Schorling JB, Roach J, Siegel M, Buturka N, Hunt DE, 

Guterbock TM, Stewart HL. A trial of church-based 

smoking cessation interventions for rural African 

Americans. Preventive Medicine 1997;26(1):92–101. 

Shelton DM, Merritt RK, Robinson RG. Tobacco control strategies. In: Slama K, editor. Tobacco and Health. 

New York: Plenum Press, 1995:367–74. 

Sherwood D, Maroney N, Stubblebine WC. Assessing 

Public Support for No-Smoking Policies: A Survey of California Residents. Claremont (CA): The Claremont 

Graduate School, The Claremont Institute for Economic Policy Studies, January 1994. 

Stillman FA, Bone LR, Rand C, Levine DM, Becker DM. 

Heart, body, and soul: a church-based smokingcessation program for urban African Americans. 

Preventive Medicine 1993;22(3):335–49. 

Stotts RC, Glynn TJ, Baquet CR. Smoking cessation 

among blacks. Journal of Health Care for the Poor and 

Underserved 1991;2(2):307–19. 

Tiedje LB, Kingry MJ, Stommel M. Patient attitudes 

concerning health behaviors during pregnancy: initial 

development of a questionnaire. Health Education Quarterly 1992;19(4):481–93. 

Tobacco Institute. The Tax Burden on Tobacco. Historical 

Compilation, Volume 31. Washington (DC): The Tobacco 

Institute, 1997. 

Tomar SL, Husten CG, Manley MW. Do dentists and 

physicians advise tobacco users to quit? Journal of the 

American Dental Association 1996;127:259–65. 

Townsend J, Roderick P, Cooper J. Cigarette smoking 

by socioeconomic group, sex, and age: effects of price, 

income, and health publicity. British Medical Journal 

1994;309(6959):923–7. 

Treviño FM, Moyer ME, Valdez RB, Stroup-Benham 

CA. Health insurance coverage and utilization of 

health services by Mexican Americans, mainland 

Puerto Ricans, and Cuban Americans. Journal of the 

American Medical Association 1991;265(2):233–7. 

Triandis HC, Marín G, Lisansky J, Betancourt H. 

Simpatía as a cultural script of Hispanics. Journal of 

Personality and Social Psychology 1984;47(6):1363–75. 

Uba L. Cultural barriers to health care for Southeast 

Asian refugees. Public Health Reports 1992;107(5):544–8. 

US Congressional Budget Office. Federal Taxation of 

Tobacco, Alcoholic Beverages, and Motor Fuels. Washington (DC): Congress of the United States, US Congressional Budget Office, August 1990. 

US Department of Health and Human Services. Preventing Tobacco Use Among Young People. A Report of the 

Surgeon General. Atlanta: US Department of Health and 

Human Services, Public Health Service, Centers for 

Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health, 1994. 

Tobacco Control and Education Efforts 309 
 

Surgeon General's Report 

US Department of Health and Human Services. You 

Can Quit Smoking: Consumer Guide. Clinical Practice 

Guideline No. 18. Rockville (MD): US Department of 

Health and Human Services, Public Health Service, 

Agency for Health Care Policy and Research. AHCPR 

Publication Nos. 96-0695 and 97-G003–G008, 1996 and 

1997. 

US Department of Health and Human Services. Synar 

Regulation Implementation: FY 97 State Compliance, Section I: Program Summary. Report to Congress. Rockville 

(MD): US Department of Health and Human Services, 

Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention, 1998. 

US General Accounting Office. Hispanic Access to Health 

Care: Significant Gaps Exist. Gaithersburg (MD): US 

General Accounting Office, Program Evaluation and 

Methodology Division. GAO/PEMD–92–6, January 

1992. 

US General Accounting Office. Hispanics’ Schooling: 

Risk Factors for Dr  ̧ opping Out and Barriers T  ̧ o Resuming 

Education. Gaithersburg (MD): US General Accounting Office, Program Evaluation and Methodology Division. GAO/PEMD–94–24, July 1994. 

Vander Martin R, Cummings SR, Coates TJ. Ethnicity 

and smoking: differences in white, black, Hispanic, and 

Asian medical patients who smoke. American Journal 

of Preventive Medicine 1990;6(4):194–9. 

Vega WA. Theoretical and pragmatic implications of 

cultural diversity for community research. American 

Journal of Community Psychology 1992;20(3):375–91. 

Vietnamese Community Health Promotion Project. 

Làm Thê’ Nào Dê Bo Hút Thuô’c? (How to Quit Smoking)  ̧  ̧ . 

San Francisco: The Vietnamese Community Health 

Promotion Project, University of California, San Francisco, Division of General Internal Medicine, 1990. 

Voorhees CC, Stillman FA, Swank RT, Heagerty PJ, 

Levine DM, Becker DM. Heart, body, and soul: impact 

of church-based smoking cessation interventions on 

readiness to quit. Preventive Medicine 1996;25(3):277–85. 

Warnecke RB, Flay BR, Kviz FJ, Gruder CL, 

Langenberg P, Crittenden KS, et al. Characteristics of 

participants in a televised smoking cessation intervention. Preventive Medicine 1991;20(3):389–403. 

Warner KE, Chaloupka FJ, Cook PJ, Manning WG, 

Newhouse JP, Novotny TE, et al. Criteria for determining an optimal cigarette tax: the economist’s perspective. Tobacco Control 1995;4(4):380–6. 

Wasserman J. How effective are excise tax increases in 

reducing cigarette smoking [editorial]? American Journal of Public Health 1992;82(1):19–20. 

Winkleby MA. The future of community-based cardiovascular disease intervention studies [editorial]. American Journal of Public Health 1994;84(9):1369–72. 

Winkleby MA, Fortmann SP, Rockhill B. Trends in cardiovascular disease risk factors by educational level: 

the Stanford Five-City Project. Preventive Medicine 

1992;21(5):592–601. 

Winkleby MA, Schooler C, Kraemer HC, Lin J, 

Fortmann SP. Hispanic versus white smoking patterns 

by sex and level of education. American Journal of Epidemiology 1995;142(4):410–8. 

310 Chapter 5 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

List of Tables and Figures 

Chapter 1 

Introduction and Summary of Conclusions 

Table 1. U.S. population distribution, by race/ 

ethnicity and Hispanic origin, and 

percentage change, 1980–1990 8 

Table 2. Selected demographic characteristics for 

the U.S. population, by race/ethnicity, 

1990 9 

Table 3. Estimated percentage distribution of 

the U.S. population, by race/ethnicity 

and Hispanic origin, 1990–2050 10 

Chapter 2 

Patterns of Tobacco Use Among Four Racial/Ethnic 

Minority Groups 

Table 1.	 Percentage of adult African Americans 

who reported being current cigarette 

smokers, overall and by gender, age, and 

education, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 22 

Table 2.	 Percentage of adult African American 

smokers who reported smoking <15, 

15–24, or ≥ 25 cigarettes per day, overall 

and by gender, age, and education, 

National Health Interview Surveys, 

United States, 1978–1995 aggregate 

data 24 

Table 3.	 Percentage of adult African American 

ever smokers who have quit, overall and 

by gender, age, and education, National 

Health Interview Surveys, United States, 

1978–1995 aggregate data 26 

Table 4.	 Current cigarette smoking status among 

persons who reported that they were 

daily smokers 1 year before being 

surveyed, Current Population Survey 

National Cancer Institute Supplement, 

1992–1993 27 

Table 5. Percentage of African American women 

of reproductive age who reported being 

current cigarette smokers, overall and by 

education, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 28 

Table 6. Percentage of live-born infants’ mothers 

who reported smoking during pregnancy, by year and race/ethnicity, U.S. 

final natality statistics, 1989–1995 29 

Table 7. Trends in the percentage of high school 

seniors who were previous-month 

smokers, by race/ethnicity and gender, 

Monitoring the Future surveys, United 

States, 1976–1979, 1980–1984, 1985–1989, 

1990–1994 32 

Table 8. Percentage of African Americans and 

whites 20–34 years of age who reported 

being current cigarette smokers, by age 

group and gender, National Health 

Interview Surveys, United States, 

1978–1995 aggregate data 33 

Table 9. Percentage of African Americans and 

whites 20–24 years of age who reported 

being current cigarette smokers, by 

education and gender, National Health 

Interview Surveys, United States, 

1978–1995 aggregate data 34 

Table 10. Percentage of African American and 

white high school seniors who reported 

recently using or not using cigarettes 

and other selected substances, Monitoring the Future surveys, United States, 

1976–1994 aggregate data 37 

Table 11. Cumulative percentages of recalled age 

at which a respondent first tried a 

cigarette and began smoking daily, 

among African American, Hispanic, and 

white men and women aged 30–39, 

National Household Surveys on Drug 

Abuse, United States, 1994–1995 40 

List of Tables and Figures 311 
 

Surgeon General's Report 

Table 12.	 Percentage of African American and 

white high school seniors who reported 

previous-month and heavy smoking, by 

selected variables, Monitoring the 

Future surveys, United States, 

1976–1994 42 

Table 13.	 Percentage of American Indian and 

Alaska Native adults who reported 

being current cigarette smokers, overall 

and by gender, age, and education, 

National Health Interview Surveys, 

United States, 1978–1995 aggregate 

data 46 

Table 14.	 Percentage of adult American Indian 

and Alaska Native smokers who reported smoking <15, 15–24, or ≥ 25 

cigarettes per day, overall and by 

gender, age, and education, National 

Health Interview Surveys, United States, 

1978–1995 aggregate data 47 

Table 15.	 Percentage of adult American Indian 

and Alaska Native ever smokers who 

have quit, overall and by gender, age, 

and education, National Health Interview Surveys, United States, 1978–1995 

aggregate data 48 

Table 16.	 Percentage of American Indian and 

Alaska Native women of reproductive 

age who reported being current cigarette 

smokers, overall and by education, 

National Health Interview Surveys, 

United States, 1978–1995 aggregate 

data 49 

Table 17.	 Percentage of American Indian and 

Alaska Native adults who reported 

being current cigarette smokers, overall 

and by region/state, gender, age, and 

education, Behavioral Risk Factor 

Surveillance System, 1988–1992 

aggregate data 50 

Table 18.	 Percentage of adult American Indian 

and Alaska Native smokers who reported smoking <15, 15–24, or ≥ 25 

cigarettes per day, overall and by 

region/state, gender, age, and education, Behavioral Risk Factor Surveillance 

System, 1988–1992 aggregate data 52 

Table 19. Percentage of adult American Indian 

and Alaska Native smokers who reported they quit smoking, overall and 

by region/state, gender, age, and 

education, Behavioral Risk Factor 

Surveillance System, 1988–1992 

aggregate data 54 

Table 20. Percentage of American Indian and 

Alaska Native women of reproductive 

age who reported being current cigarette 

smokers, overall and by region/state, 

Behavioral Risk Factor Surveillance 

System, 1988–1992 aggregate data 56 

Table 21. Percentage of adult Asian Americans 

and Pacific Islanders who reported 

being current cigarette smokers, overall 

and by gender, age, and education, 

National Health Interview Surveys, 

United States, 1978–1995 aggregate 

data 57 

Table 22. Percentage of adult Asian American and 

Pacific Islander smokers who reported 

smoking <15, 15–24, or ≥ 25 cigarettes 

per day, overall and by gender, age, and 

education, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 58 

Table 23. Percentage of adult Asian American and 

Pacific Islander ever smokers who have 

quit, overall and by gender, age, and 

education, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 59 

Table 24. Percentage of adult Asian American and 

Pacific Islander women of reproductive 

age who reported being current cigarette 

smokers, overall and by education, 

National Health Interview Surveys, 

United States, 1978–1995 aggregate 

data 60 

Table 25. Percentage of Chinese and Vietnamese 

men who reported they smoke and the 

number of cigarettes they smoke per 

day, by age, education, annual household income, and level of acculturation, 

Behavioral Risk Factor Surveillance 

System, California, 1990 and 1991 

aggregate data 62 

312 List of Tables and Figures 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 26.	 Percentage of adult Asian Americans 

and Pacific Islanders who reported 

being current smokers, overall and by 

gender, age, and education, Screener 

Survey, California, 1990 and 1991 

aggregate data 63 

Table 27.	 Summary of selected findings on the 

percentage of Asian American and 

Pacific Islander adults who smoke, 

overall and by gender, 1975–1995 64 

Table 28.	 Percentage of adult Hispanics who 

reported being current cigarette smokers, overall and by gender, age, and 

education, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 67 

Table 29.	 Percentage of adult Hispanic smokers 

who reported smoking <15, 15–24, or 

≥ 25 cigarettes per day, overall and by 

gender, age, and education, National 

Health Interview Surveys, United States, 

1978–1995 aggregate data 68 

Table 30.	 Percentage of adult Hispanic ever 

smokers who have quit, overall and by 

gender, age, and education, National 

Health Interview Surveys, United States, 

1978–1995 aggregate data 70 

Table 31.	 Percentage of Hispanic women of 

reproductive age who reported being 

current cigarette smokers, overall and by 

education, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 71 

Table 32.	 Percentage of self-reported cigarette 

brand use among adult current cigarette 

smokers, overall and by race/ethnicity 

and gender, National Health Interview 

Surveys (NHIS) 1978–1980 combined, 

Adult Use of Tobacco Survey (AUTS) 

1986, and NHIS 1987 80 

Table 33.	 Percentage of self-reported cigarette 

brand use among adolescent current 

cigarette smokers, by race/ethnicity, 

Teenage Attitudes and Practices Survey 

(TAPS), 1989 and 1993 82 

Table 34.	 Relationship between smoking status 

and race/ethnicity among adults, before 

and after controlling for education, 

National Health Interview Surveys, 

United States, 1987, 1988, 1990, and 1991 

aggregate data 84 

Table 35.	 Percentage of all adults and nonsmokers 

who reported levels of exposure to 

environmental tobacco smoke in the 

home, by race/ethnicity and gender, 

National Health Interview Surveys, 

United States, 1991–1993 aggregate 

data 87 

Table 36.	 Age-adjusted prevalence of current 

cigarette smoking among adults, overall 

and by race/ethnicity and gender, 

National Health Interview Surveys, 

United States, 1994 and 1995 aggregate 

data 88 

Table 37.	 Cigarette smoking status and number of 

cigarettes smoked per day among 

adults, overall and by race/ethnicity and 

gender, National Health Interview 

Surveys, United States, 1987, 1988, 1990, 

and 1991 aggregate data 90 

Table 38.	 Percentage of adults who reported using 

cigars, pipes, chewing tobacco, snuff, or 

any form of tobacco, overall and by 

race/ethnicity and gender, National 

Health Interview Surveys, United States, 

1987 and 1991 aggregate data 92 

Table 39.	 Percentage of white adults who reported 

being current cigarette smokers, overall 

and by gender, age, and education, 

National Health Interview Surveys, 

United States, 1965–1995 98 

Table 40.	 Percentage of adult white smokers who 

reported smoking <15, 15–24, and ≥ 25 

cigarettes per day, overall and by 

gender, age, and education, National 

Health Interview Surveys, United States, 

1965–1995 100 

Table 41.	 Percentage of adult white ever smokers 

who have quit, overall and by gender, 

age, and education, National Health 

Interview Surveys, United States, 

1965–1995 104 

List of Tables and Figures 313 
 

Surgeon General's Report 

Table 42. Percentage of white women of reproductive age who reported being current 

cigarette smokers, overall and by 

education, National Health Interview 

Surveys, United States, 1965–1995 106 

Table 43. Percentage of white adults who reported 

being current cigarette smokers, overall 

and by gender, age, and education, 

National Health Interview Surveys, 

United States, 1978–1995 aggregate 

data 107 

Table 44. Percentage of adult white smokers who 

reported smoking <15, 15–24, ≥25 

cigarettes per day, overall and by 

gender, age, and education, National 

Health Interview Surveys, United States, 

1978–1995 aggregate data 108 

Table 45. Percentage of adult white ever smokers 

who have quit, overall and by gender, 

age, and education, National Health 

Interview Surveys, United States, 

1978–1995 aggregate data 110 

Table 46. Percentage of white women of reproductive age who reported being current 

cigarette smokers, overall and by 

education, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 111 

Table 47. Percentage of adult African Americans 

who reported being current cigarette 

smokers, overall and by gender, age, and 

education, National Health Interview 

Surveys, United States, 1965–1995 112 

Table 48. Percentage of adult African American 

smokers who reported smoking <15, 

15–24, or ≥25 cigarettes per day, overall 

and by gender, age, and education, 

National Health Interview Surveys, 

United States, 1965–1995 114 

Table 49. Percentage of adult African American 

ever smokers who have quit, overall and 

by gender, age, and education, National 

Health Interview Surveys, United States, 

1965–1995 118 

Table 50. Percentage of African American women 

of reproductive age who reported being 

current cigarette smokers, overall and by 

education, National Health Interview 

Surveys, United States, 1965–1995 120 

Table 51. Sample sizes for birth cohorts, by 

gender, race/ethnicity, and education, 

National Health Interview Surveys, 

1978–1980, 1987 and 1988 combined, 

and Hispanic Health and Nutrition 

Examination Survey, 1982–1984 122 

Table 52. Comparison of current smoking prevalence between reconstructed estimates 

from National Health Interview Surveys 

(NHISs), 1987 and 1988 combined, NHIS 

cross-sectional survey estimates, and 

Gallup poll estimates 124 

Figure 1. Trends in the prevalence of cigarette 

smoking among African American 

and white men and women, National 

Health Interview Surveys, United States, 

1965–1995 23 

Figure 2. Trends in daily smoking among African 

American and white high school seniors, 

by gender, United States, 1977–1996 30 

Figure 3. Trends in daily smoking among 

African American, Hispanic, and 

white high school seniors, United States, 

1977–1996 31 

Figure 4. Trends in smoking among African 

Americans and whites aged 20–34 years, 

United States, 1978–1995 35 

Figure 5. Use of cigarettes and alcohol among 

African American and white high school 

seniors, United States, 1976–1979 and 

1990–1994 38 

Figure 6. Use of cigarettes and illicit drugs among 

African American and white high school 

seniors, United States, 1976–1979 and 

1990–1994 39 

Figure 7. Cigarette smoking prevalence among 

successive birth cohorts of African 

American men, by education, National 

Health Interview Surveys, United States, 

1978–1980, 1987, and 1988 75 

Figure 8. Cigarette smoking prevalence among 

successive birth cohorts of African 

American women, by education, National Health Interview Surveys, United 

States, 1978–1980, 1987, and 1988 76 

314 List of Tables and Figures 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Figure 9. Cigarette smoking prevalence among 

successive birth cohorts of Hispanic 

men, by education, Hispanic Health and 

Nutrition Examination Survey, 1982– 

1984 77 

Figure 10. Cigarette smoking prevalence among 

successive birth cohorts of Hispanic 

women, by education, Hispanic Health 

and Nutrition Examination Survey, 

1982–1984 77 

Figure 11. Reconstructed prevalence of smoking 

among African American adults aged 

20–29 years, by gender and education, 

National Health Interview Surveys, 

United States, 1910–1988 78 

Figure 12. Reconstructed prevalence of smoking 

among Hispanic adults aged 20–29 

years, by gender and education, Hispanic Health and Nutrition Examination 

Surveys, 1920–1984 79 

Figure 13. Trends in the age-adjusted prevalence 

of current cigarette smoking among 

African American, American Indian 

and Alaska Native, Asian American and 

Pacific Islander, Hispanic, and white 

adults, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 88 

Figure 14. Trends in the age-adjusted prevalence 

of current cigarette smoking among 

African American, American Indian and 

Alaska Native, Asian American and 

Pacific Islander, Hispanic, and white 

men, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 89 

Figure 15. Trends in the age-adjusted prevalence 

of current cigarette smoking among 

African American, American Indian and 

Alaska Native, Asian American and 

Pacific Islander, Hispanic, and white 

women, National Health Interview 

Surveys, United States, 1978–1995 

aggregate data 89 

Figure 16. Comparison of smoking prevalence 

estimates from selected U.S. surveys, 

1910–1991 123 

Chapter 3 

Health Consequences of Tobacco Use 

Among Four Racial/Ethnic Minority Groups 

Table 1. Death rates per 100,000 U.S. residents for 

malignant diseases of the respiratory 

system, by race/ethnicity and gender, 

United States, 1950–1995, selected 

years 139 

Table 2. Age-adjusted death rates for selected 

smoking-related causes of death, by 

race/ethnicity and gender, United States, 

1992–1994 141 

Table 3. Death rates for lung cancer among 

American Indians and Alaska Natives, 

by Indian Health Service (IHS) area, 

1984–1988 146 

Table 4. Age-adjusted death rates for selected 

smoking-related causes of death among 

Mexican Americans, Puerto Rican 

Americans, and Cuban Americans, 

United States, 1992–1994 148 

Table 5. Odds ratios for the risk of lung cancer, 

by gender, race/ethnicity, and smoking 

status, case-control study, New Mexico, 

1980–1982 149 

Table 6. Age-adjusted incidence and death rates 

for selected smoking-related cancers, by 

race/ethnicity and gender, National 

Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program, 

1988–1992 150 

Table 7. Age-adjusted cancer death rates among 

American Indians and Alaska Natives at 

all 12 Indian Health Service areas, 

United States, 1984–1988 155 

Table 8. Odds ratios and 95% confidence intervals for the risk of oral cancer associated 

with cigarette smoking, by race/ 

ethnicity and smoking status, 1984– 

1985 156 

Table 9. Odds ratios for the risk of urinary 

bladder cancer associated with smoking, 

by gender, race/ethnicity, and smoking 

status 157 

Table 10. Rates of selected infant outcomes, by 

mother’s race/ethnicity, United 

States 168 

List of Tables and Figures 315 
 

Surgeon General's Report 

Table 11. Risk of sudden infant death syndrome 

associated with smoking, by race/ 

ethnicity, selected studies, United 

States 170 

Table 12. Exposure to household smoke among 

children 5 years of age and younger 

and percentage distribution, by level 

of exposure since birth and selected 

characteristics, United States, 1988 173 

Table 13. Criteria for drug dependence 176 

Table 14. American Psychiatric Association 

diagnostic criteria for substance 

dependence 177 

Table 15. Human pharmacology of nicotine 178 

Table 16. Incidence of nicotine withdrawal 

symptoms, United States 179 

Table 17. Percentage of adult smokers who 

reported that they smoked their first 

cigarette within 10 minutes and within 

30 minutes of awakening, by race/ 

ethnicity and number of cigarettes 

smoked per day, National Health 

Interview Survey, United States, 

1987 182 

Table 18. Percentage of men and women who 

considered smoking a habit or addiction, 

overall and by smoking status, Current 

Population Survey, United States, 1992– 

1993 184 

Figure 1. Incidence of cancer of the lung and 

bronchus, by race/ethnicity and gender, 

National Cancer Institute’s Surveillance, 

Epidemiology, and End Results (SEER) 

Program, 1973–1994 138 

Figure 2. Age-adjusted lung cancer death rates 

among American Indian and Alaska 

Native men in selected states compared 

with rates among all U.S. men, 

1968–1987 144 

Figure 3. Age-adjusted lung cancer death rates 

among American Indian and Alaska 

Native women in selected states compared with rates among all U.S. women, 

1968–1987 145 

Figure 4. SEER cancer incidence and U.S. death 

rates, 1988–1992, ratio of African 

American rate to white rate for all 

ages, by cancer site 154 

Figure 5. Serum cotinine levels by number of 

cigarettes smoked daily for African 

Americans, Mexican Americans, and 

whites, National Health and Nutrition 

Examination Survey, United States, 

1988–1991 180 

Chapter 4 

Factors That Influence Tobacco Use Among 

Four Racial/Ethnic Minority Groups 

Table 1.	 High school seniors’ perceptions 

about the risks associated with cigarette 

smoking, Monitoring the Future surveys, United States, 1980–1989 230 

Chapter 5 

Tobacco Control and Education Efforts Among 

Members of Four Racial/Ethnic Minority Groups 

Table 1.	 Percentage of adult smokers who would 

like to stop smoking, by race/ethnicity 

and gender, National Health Interview 

Survey, United States, 1993 261 

Table 2.	 Adults’ beliefs about the health effects of 

smoking, by race/ethnicity, gender, and 

smoking status, National Health Interview Survey, United States, 1992 264 

Table 3.	 Adults’ beliefs about minors’ ease in 

purchasing cigarettes and other tobacco 

products, by race/ethnicity, smoking 

status, and gender, Current Population 

Survey, United States, 1992–1993 267 

Table 4.	 Public support for and beliefs about 

policies regarding tobacco access and 

marketing, by selected characteristics, 

Robert Wood Johnson Foundation Youth 

Access Survey, 1994 270 

Table 5.	 Percentage of adult smokers who have 

received advice to quit smoking from 

either a medical doctor or a dentist, by 

race/ethnicity and gender, Current 

Population Survey, United States, 1992– 

1993 285 

316 List of Tables and Figures 
 

Table 6.	 Percentage of adults who reported that 

no one is allowed to smoke anywhere 

inside the home, by race/ethnicity, 

smoking status, and gender, Current 

Population Survey, United States, 1992– 

1993 288 

Table 7.	 Percentage of adults who think that 

smoking should be allowed in some 

areas or not allowed at all in selected 

public locations, by race/ethnicity and 

smoking status, Current Population 

Survey, United States, 1992–1993 290 

Table 8.	 Percentage of adults who think that the 

advertising of tobacco products should 

be always allowed or not allowed at all, 

by race/ethnicity, smoking status, and 

gender, Current Population Survey, 

United States, 1992–1993 294 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Table 9. Percentage of Californians who support 

curtailment of tobacco advertising and 

promotion efforts, by race/ethnicity, 

1992 295 

Table 10. Percentage of adults who think that 

giving away free tobacco samples 

should be always allowed or not allowed at all, by race/ethnicity, smoking 

status, and gender, Current Population 

Survey, United States, 1992–1993 296 

Table 11. Public beliefs about and support for 

policies related to nicotine and tobacco 

product regulation, Robert Wood 

Johnson Foundation Youth Access 

Survey, 1994 298 

Figure 1. Billboard used by the California Department of Health Services in targeting 

Hispanics to quit smoking 261 

List of Tables and Figures 317 
 
 

CI confidence interval 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Glossary 

ACS American Cancer Society 

AIDS acquired immunodeficiency 

syndrome 

ALA American Lung Association 

APA American Psychiatric Association 

ASSIST American Stop Smoking 

Intervention Study 

AUTS Adult Use of Tobacco Survey 

BRFSS Behavioral Risk Factor Surveillance 

System 

CARDIA Coronary Artery Risk Development 

in (Young) Adults 

CDC Centers for Disease Control and 

Prevention 

CES-D Center for Epidemiological 

Studies Depression Scale 

CHD coronary heart disease 

CIS Cancer Information Service 

COMMIT Community Intervention Trial 

for Smoking Cessation 

COPD chronic obstructive pulmonary 

disease 

COSSMHO National Coalition of Hispanic 

Health and Human Services 

Organizations 

COST Churches Organized to Stop Tobacco 

CPS Current Population Survey 

CPS-I Cancer Prevention Study I 

DNA deoxyribonucleic acid 

DOC Doctors Ought to Care 

DSM-IIITM	 Diagnostic and Statistical Manual 

of Mental Disorders, Third Edition 

DSM-IVTM Diagnostic and Statistical Manual 

of Mental Disorders, Fourth Edition 

ETS environmental tobacco smoke 

FAO Food and Agriculture Organization 

of the United Nations 

FDA Food and Drug Administration 

FEV1 forced expiratory volume after one 

second 

FTC Federal Trade Commission 

G6PD glucose-6-phosphate dehydrogenase 

GAO U.S. General Accounting Office 

GAS Great American Smokeout 

HHANES Hispanic Health and Nutrition 

Examination Survey 

HMO health maintenance organization 

HRSA Health Resources and Services 

Administration 

ICD Manual of the International Statistical 

Classification of Diseases, Injuries and 

Causes of Death 

ICD-9 International Classification of Diseases, 

Ninth Revision 

IHD ischemic heart disease 

IHS Indian Health Service 

LBW low birth weight 

LST Life Skills Training 

MTF Monitoring the Future surveys 

MTV Music Television 

NAAAPI National Association of African 

Americans for Positive Imagery 

NAACP National Association for the 

Advancement of Colored People 

NBLIC National Black Leadership Initiative 

on Cancer 

Glossary 319 
 

Surgeon General's Report 

NCHS National Center for Health Statistics 

NCI National Cancer Institute 

NHANES I National Health and Nutrition 

Examination Survey I 

NHANES II National Health and Nutrition 

Examination Survey II 

NHANES III National Health and Nutrition 

Examination Survey III 

NHEFS NHANES I Epidemiologic 

Follow-up Study 

NHIS National Health Interview Survey 

NHSDA National Household Survey on 

Drug Abuse 

NIDA National Institute on Drug Abuse 

NMA National Medical Association 

NMFS National Mortality Followback 

Survey 

NMIHS National Maternal and Infant 

Health Survey 

OR odds ratio 

PUSH People United to Save Humanity 

RFLP restriction fragment length 

polymorphism 

RWJF The Robert Wood Johnson 

Foundation 

SAIAN	 Survey of American Indians and 

Alaska Natives 

SEER	 Surveillance, Epidemiology, and 

End Results Program 

SESUDAAN	 Standard Errors Program for 

Computing of Standardized Rates 

from Sample Survey Data 

SHOUT	 Students Helping Others 

Understand Tobacco 

SIDS	 sudden infant death syndrome 

SMART	 Self-Management and Resistance 

Training 

STAT	 Stop Teenage Addiction to Tobacco 

SUDAAN	 Professional Software for Survey 

Data Analysis 

TAPS	 Teenage Attitudes and Practices 

Survey 

TAPS-II	 Teenage Attitudes and Practices 

Survey II 

UNCF	 United Negro College Fund 

USDHEW	 U.S. Department of Health, 

Education, and Welfare 

USDHHS	 U.S. Department of Health and 

Human Services 

YRBS	 Youth Risk Behavior Survey 

320 Glossary 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups 

Index 

A 

A Su Salud 282
 

Absorption of nicotine. See Nicotine pharmacology
 

Abstinent smokers, effects of nicotine
 

administration 177
 

Academic performance and smoking initiation 36,
 

228
 

Access of minors to tobacco products
 

ease of access 266–269
 

enforcement of legislation 266, 268
 

over-the-counter sales of cigarettes 266, 269
 

perception of ease by adult members of
 

ethnic groups 267
 

vending machines 268–269
 

Acculturation
 

effectiveness of warning labels 299
 

factor in coronary heart disease incidence 163
 

Hispanics 228, 237
 

initiation of tobacco use 234–235
 

smoking cessation 235, 237
 

smoking prevalence 61, 65, 235
 

tobacco advertising and promotion 227, 229
 

Actors, appearance in tobacco ads 243
 

Addiction, nicotine. See Nicotine dependence
 

and addiction
 

Adolescent African American mothers and use
 

of tobacco 27–28
 

Adolescent Health Survey 49
 

Adolescents
 

cigarette brand preference 80–83 

risk factors to predict cigarette smoking 

228-229, 230–231
 

smoking initiation 40, 225-229
 

smoking prevalence 28–44
 

use of smokeless tobacco 44, 49–50, 174–175
 

See also Youth
 

Adult literacy programs tobacco industry
 

support 217
 

Adult Use of Tobacco Survey (AUTS) 21, 79, 80,


 96 (description) 

Adults, psychosocial factors of use 225–238 

Advertising, tobacco products 

bans, ethnic group support 293–297
 

billboards 215, 221, 222, 244, 293
 

convenience stores 222
 

endorsements 242
 

ethnic targeting 13, 220–224, 240–244
 

ethnicity of models 240–242
 

immigrants 223, 241
 

impact on youth 220
 

in-store advertising displays 222
 

print advertisements 214–215, 221
 

revenues 214–215
 

role models 242
 

stimulation of cigarette consumption
 

207, 220–223
 

targeting youth 207
 

television ban 214
 

African American Tobacco Control Network of
 

California 297
 

Age
 

airflow obstruction and smoking,
 

Japanese men 159
 

and stroke incidence, Asian Americans 165
 

at smoking onset 36
 

differences in smoking prevalence, by ethnicity
 

African Americans 22–23
 

American Indians and Alaska
 

Natives 46
 

Asian Americans and Pacific
 

Islanders 61–63
 

Hispanics 66–67
 

Aggregation problems in data collection.
 

See Data collection and analysis
 

Alameda County Low Birth Weight Study
 

Group 168
 

Alcohol use and smoking
 

among youth 37–38
 

Alpha Kappa Alpha Sorority 216
 

American Cancer Society (ACS) 280, 292, 295
 

American Health Foundation study 156
 

American Indian Cancer Control Project of
 

California 276, 286
 

American Lung Association (ALA) 274, 275, 295
 

American Psychiatric Association (APA) diagnostic
 

criteria for drug dependence 177
 

American Stop Smoking Intervention Study
 

(ASSIST) 269
 

Anemia and smoking, effects on birth weight 171
 

Angina. See also Coronary heart disease (CHD)
 

incidence and mortality 

Antismoking campaigns. See Mass media; Schoolbased health education approaches 

Antismoking policies. See Smoking bans in 

public places 

Arts, tobacco industry support of. See Tobacco 

industry, support for arts
 

Asian Americans for Community Involvement 289
 

Asian American Health Forum 297
 

Asian Pacific Islander Tobacco Education
 

Network 297
 

Asthma 160
 

Index 321
 
 

Surgeon General’s Report 

Athletes, appearance in tobacco ads 214, 243
 

Athletic events. See Sponsorship by tobacco
 

industry; Cigarette promotion campaigns
 

Attempts to quit smoking. See Smoking cessation
 

programs 

Attention. See Nicotine, physiological effects 

Attitudes toward tobacco use 

among adults 264–265
 

among youth 36, 38, 41
 

belief that smoking is addictive 183–184
 

immigrants to the United States 262
 

parental attitudes 40
 

smoking in public places 287–291
 

See also Cultural values
 

Attrition rates in group approaches to cessation. 

See Smoking cessation, attrition rate 

B 

Barbers/beauty parlor operators, involvement in
 

cessation efforts 287
 

Behavioral Risk Factor Surveillance System (BRFSS)
 

American Indians and Alaska Natives 45, 46,
 

50, 51–56, 144
 

Asian Americans and Pacific Islanders 56, 58,
 

59, 61, 62–64
 

description of 21, 95
 

ethnic differences in quitting smoking 183
 

Hispanics 164
 

measures of tobacco use 97, 98
 

Behavioral alternatives to cigarette smoking 260
 

Bill of Rights touring exhibition 218, 222
 

Billboard advertising. See Advertising, tobacco
 

control, tobacco products 

Biochemical markers of tobacco use
 

ethnic differences 179–181
 

measurements among pregnant women 167
 

smokeless tobacco users 183
 

youth 32–34
 

Birth weight. See Infant outcomes, effects of 

smoking during pregnancy
 

Black Clergy for Substance Abuse Prevention 286
 

Black History Month 222, 296
 

Bladder cancer. See Urinary bladder cancer
 

Blood pressure. See Hypertension
 

Boston, marketing of X brand cigarettes 295–296
 

Boy and Woman Bear culturally appropriate software
 

package 273
 

Brain function. See Nicotine, physiological effects
 

Brand preference 79–83. See also Cigarette brands
 

Brand recognition. See also Cigarette promotion
 

campaigns; Cigarette brands 

Bronchitis 141, 158, 160
 

Bureau of the Census 187
 

Bureau of Vital Statistics 187
 

C 

California
 

“Proposition 99” 217, 275
 

smoking cessation hot lines 277
 

smoking cessation efforts 297
 

use of revenue from cigarette taxes 277
 

California Department of Health Services 284
 

California Tobacco Survey 68, 182, 268, 283–284,
 

289, 292
 

Cancer. See specific types of cancer
 

Cancer Information Service (CIS) hot line, National
 

Cancer Institute 277
 

Cancer Prevention Study I (CPS-I) 161
 

cancer registries 138, 147
 

Carbon monoxide as an indicator of smoking 33, 34
 

Cardiovascular disease. See also Coronary heart
 

disease (CHD) incidence and mortality
 

Cardiovascular effects of nicotine. See Nicotine,
 

physiological effects
 

Center for Epidemiological Studies Depression
 

Scale 234, 237
 

Centers for Disease Control and Prevention
 

(CDC) 282, 284
 

Cerebrovascular disease
 

African Americans 165
 

American Indians and Alaska Natives 165
 

Asian Americans and Pacific Islanders
 

165–166
 

Hispanics 166
 

Ceremonial and religious rites involving
 

tobacco 44, 209
 

Cervical cancer 152
 

Cessation of smoking. See Smoking cessation
 

programs
 

Charleston Heart Study 161
 

Chewing tobacco. See Smokeless tobacco use
 

Chicago Community Based Interventions for
 

Low-Income African Americans 281
 

Chicago Lung Association’s multifaceted smoking
 

cessation intervention 281
 

Child Health and Development Studies 167
 

Children
 

as motivators to quit smoking among
 

Hispanics 260
 

exposure to environmental tobacco smoke
 

in home 173
 

involvement in smoking cessation
 

campaigns 269, 271
 

322 Index 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups

lung function and environmental tobacco 

smoke 172
 

Chinese Community Smoke-Free Project 277
 

Cholesterol and cardiovascular disease risk 162
 

Chronic obstructive pulmonary disease (COPD)
 

African Americans 158
 

American Indians and Native 

Americans 158–159 

Asian Americans and Pacific Islanders 159
 

Hispanics 159–160
 

Churches Organized to Stop Tobacco (COST) 296
 

Cigar smoking 91–94
 

Cigarette brands
 

555 State Express 218
 

Alpine 242
 

American Spirit 223
 

Belair 242
 

Benson & Hedges 79, 80, 82
 

Camel 79, 80, 82, 220, 224, 243
 

Chesterfield 242
 

Dorado 220
 

Eve 243
 

Kent 79, 80, 243
 

Kool 79, 80, 82, 243
 

L&M 243
 

Lucky Strike 243
 

Marlboro 79, 80, 82, 83, 218, 220, 224, 242,
 

243
 

Merit 79, 81, 82
 

Mild Seven 223
 

More 219
 

Newport 79, 81, 82, 220–221, 224, 242
 

Oasis 242
 

Old Gold 241
 

Pall Mall 79, 81
 

Parliament 219
 

Richmond 242
 

Rio 220
 

Riviera 242
 

Salem 79, 81, 224, 242
 

Salem Extra 244
 

Spring 242
 

Spud 242
 

Super M 244
 

Uptown 222, 224, 294
 

Vantage 79, 81
 

Viceroy 243
 

Virginia Slims 79, 81, 223–224
 

Winston 79, 81, 82, 243
 

X 224, 295–296
 

See also Brand preference; Brand recognition; 

Cigarette promotion campaigns 

Cigarette consumption 

among ethnic groups 

African Americans 22–28, 41–43, 74–78, 

112–121 

American Indians and Alaska 

Natives 44–55 

Asian Americans and Pacific 

Islanders 56–66 

Hispanics 66–74, 75–77 

targeted ads as external cues to 

smoke 223–224 

Cigarette manufacturers. See Tobacco companies 

Cigarette prices. See Revenues 

Cigarette promotion campaigns 

Chesterfield film campaign 242
 

coupons 223, 294
 

cultural events 213, 218–219, 297. See also
 

Tobacco industry, support for ethnic 

communities, pride, and culture
 

Marlboro Man 243
 

Marlboro Tour ’93 211
 

samples 296
 

sports events 294
 

Viceroy race car driver 243
 

See also Advertising, tobacco products; Brand
 

recognition; Cigarette brands
 

Cigarettes, hand-rolled, lung cancer death rate 149
 

Civil rights movement 243
 

Clean air policies. See Smoking bans in public places
 

Coalition Against Billboard Advertising of Alcohol
 

and Tobacco 297
 

Coalition Against Uptown Cigarettes 295
 

Cocaine use in conjunction with cigarette
 

smoking 37
 

Cognition. See Nicotine, physiological effects
 

Committee to Prevent Cancer Among Blacks 295
 

Communication skills training for youth 278
 

Community
 

approach to smoking cessation 278–283
 

dependence on tobacco industry 213–219
 

loyalty to tobacco industry 213
 

meeting of community leaders in
 

Greensboro 297
 

mobilization/involvement in antitobacco
 

campaigns
 

California 297
 

Uptown cigarettes 294–295
 

X cigarettes 295–296
 

projects, limitations of 263, 265, 293
 

volunteer health representatives 282
 

Community Intervention Trial (COMMIT) for
 

Smoking Cessation 181, 183, 236, 260
 

Congressional candidates, campaign support from
 

tobacco industry 217
 

Index 323
 
 

Surgeon General’s Report 

Congressional Hispanic Caucus 215
 

Consumer Expenditure Survey Interview
 

Survey 292
 

Coping mechanism, cigarette smoking 275
 

Coronary Artery Risk Development in (Young)
 

Adults (CARDIA) 172, 181, 186
 

Coronary heart disease (CHD) incidence and
 

mortality
 

African Americans 160–161
 

American Indians and Alaska Natives
 

161–162 

Asian Americans and Pacific Islanders 

162–163 

Hispanics 163–164 

Cotinine. See Biochemical markers of tobacco use 

Cultural events, tobacco industry support of. 

See Tobacco industry, support for cultural events 

Cultural values
 

as depicted in tobacco ads 222–224
 

cigarettes as indicator of affluence 222–224
 

Hispanic attitudes toward smoking 223
 

tobacco as a gift 210
 

See also Attitudes toward tobacco use; Social
 

influences 

Current Population Survey (CPS) 

attitudes concerning minors’ ease of access to 

tobacco products 267
 

ban on tobacco samples 293
 

classification of ethnicity 186, 187
 

CPS-I 161
 

efforts to restrict youth access to tobacco 266
 

employer-provided smoking cessation
 

programs 286
 

ethnic differences in prevalence 87
 

ethnic differences in quitting smoking 183,
 

184
 

Hispanics and coronary heart disease 163
 

quitting behavior 25, 48, 57, 70
 

workplace/public place smoking
 

restrictions 288, 289, 290–291
 

Current smokers, definition of 97
 

D 

Dance troupes, tobacco industry support of 219
 

Data collection and analysis
 

accuracy of findings on youth smoking 

prevalence 31–36 

aggregation problems 239
 

bias against Asian Americans with low 

English skills 61
 

bias in selection for studies 61
 

bias of findings 31
 

differential misclassification bias 30–32, 34
 

differential school dropout rates, African
 

American youth 31, 32, 228
 

multivariable logistic regression technique
 

83, 85
 

noncomparability of tobacco use studies 238
 

nongeneralizability of tobacco use studies 238
 

nonreporting problems in tobacco use
 

studies 238
 

reporting bias 31, 239
 

retrospective analysis methodology 74
 

sources of data 95–96
 

tobacco smoke exposure, infant
 

outcomes 168–171
 

unavailability of data on specific ethnic
 

groups 44, 56, 259, 277
 

Death rates
 

by cancer
 

cervix/uteri 148, 150, 152, 153, 155
 

esophagus 148, 150, 153
 

kidney/renal pelvis 148, 150, 155
 

larynx 148, 155
 

lung/bronchus 144, 146, 148, 150
 

oral/pharynx 148, 153–155
 

pancreas 152
 

stomach 155
 

urinary/bladder, 152, 156
 

by ethnicity 139, 144, 146
 

Decision-making skills training for youth 271
 

Decline in smoking. See Smoking prevalence,
 

decline in smoking 

Definitions
 

cigarette smoking and cessation 97
 

number of cigarettes smoked daily 97
 

use of cigars, pipes, and smokeless tobacco 97
 

Dentists, advice to patients 285
 

Depressive symptoms and smoking 234
 

See also Center for Epidemiological Studies
 

Depression Scale
 

Diagnostic and Statistical Manual of Mental 

Disorders, Fourth Edition (DSM-IVTM) 179, 181
 

Doctors, in cigarette ads 243
 

Doctors Ought to Care (DOC) 215
 

Don’t Let Your Dreams Go Up in Smoke 286
 

Dropouts, high school 228
 

Drug use and smoking. See type of drug
 

E 

Economics
 

dependency on tobacco sales, American Indian
 

reservations 213
 

efforts to reduce tobacco use 292–293
 

324 Index 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups

expenditures on tobacco promotion in ethnic 

communities 213–219 

Education 

by ethnic group
 

African Americans 83, 84
 

American Indians and Alaska Natives
 

83, 84
 

Asian Americans and Pacific Islanders 

83, 84
 

Hispanics 83, 84
 

levels of, and smoking 25, 26, 28
 

Educational materials, smoking intervention.
 

See Smoking cessation programs
 

Elimination of nicotine. See Nicotine pharmacology
 

Emphysema 158, 160
 

Employment
 

employer antismoking policies 287–288
 

employer-provided smoking cessation
 

programs 286
 

labor force composition of tobacco
 

factories 208–209 

English proficiency. See Language/linguistics 

Environmental Protection Agency 

assessment of environmental tobacco smoke
 

risks 287–289
 

Environmental tobacco smoke (ETS)
 

exposure and ethnicity 86–87, 172–173, 287,
 

289
 

exposure in public places 287–291
 

exposure to household smoke 288
 

fetal exposure 167
 

infant outcomes 167–171
 

nonsmokers’ exposure 172–173
 

perceived dangers of 261–263
 

pregnant women 285
 

Sudden Infant Death Syndrome 169–171
 

workplace exposure 287–288
 

See also Smoking bans in public places
 

Esophageal cancer 151–153 

Ethnic groups
 

definition of 7–8, 186–187
 

demographic characteristics 8–11
 

exclusion from tobacco studies 61
 

health outcomes 187
 

Ethnic labels, see Ethnic groups, definition of
 

Ever smokers, definition 97
 

F 

Fagerström dependence questionnaire 179
 

Familialism 212
 

Federal Trade Commission 140, 181
 

Federal workplace antismoking policies 287–288 

Fetal morbidity and mortality. See Infant outcomes, 

effects of smoking during pregnancy
 

Filters, packaging of Uptown cigarettes 224
 

Focus groups 40, 286
 

Food and Agriculture Organization of the
 

United Nations 211
 

Food and Drug Administration 207, 266, 297
 

Food, Tobacco, Agriculture, and Allied Workers
 

Union 209
 

For You and Your Family 284
 

Forced expiratory volume as a measure of
 

pulmonary function 159
 

Former smokers, definition 97
 

Freedom from Smoking® for You and Your Family 281
 

Freedom from Smoking in 20 Days 281
 

Funding initiatives for public health 6
 

G 

Gateway Program 217
 

Gender differences
 

smoking prevalence
 

African Americans 22–24, 41
 

American Indians and Alaska
 

Natives 44–48, 50–56 

Asian Americans and Pacific 

Islanders 56–59 

Hispanics 66–69 

smoking trends national data 23–28, 78–81
 

General Social Survey 233
 

Genetic risk, lung cancer and CYP1A1 gene 142
 

Gingival bleeding and recession 174
 

See also Periodontal disease 

Government regulation of cigarettes, 

support for 298–299
 

Great American Smokeout 280, 283
 

Great Alaska Spit-Out 273
 

Group approaches to smoking cessation 277–278
 

Guide to Black Organizations 217
 

H 

Harlem Dowling-West Side Center for Children 

and Family Services 216
 

Harlem Hospital 221
 

Health care facility access 277, 283–284
 

Health care providers 283–284, 285
 

Health consequences/risks of tobacco use
 

knowledge of
 

among adults 235, 264–265
 

among blue collar workers 263
 

Index 325
 
 

I 

Surgeon General’s Report 

among ethnic groups 12, 265
 

among pregnant women 171
 

Health insurance 216, 263
 

Health Status of Minorities and Low-Income Groups 6
 

Healthy People 2000 5
 

Heart, Body, and Soul 286
 

Heart attack. See Myocardial infarction
 

Hey, Girlfriend, Let’s Talk About Smoking and You 285
 

Hispanic Health and Nutrition Examination Survey 

(HHANES) 

chronic obstructive pulmonary disease 

159
 

cigarette smoking prevalence
 

among adults 66–67, 79
 

among successive birth cohorts 74, 76,
 

122
 

among women of reproductive age 71
 

among young people 72
 

description of 21, 95
 

environmental tobacco smoke and clean indoor
 

air policies 287
 

long-term trends in cigarette smoking 78
 

methodological issues 186
 

quitting behavior 183
 

Hispanic/Latino Tobacco Control Network 297
 

History of tobacco use
 

by ethnic group
 

African Americans 208–209
 

American Indians and Alaska
 

Natives 209–210 

Asian Americans and Pacific 

Islanders 211–212 

Hispanics 212
 

Honolulu Heart Program 159
 

Housing projects 236, 263
 

Hypertension 160, 162, 163
 

Immigration, impact on smoking prevalence 

61, 234
 

In-store advertising displays. See Advertising,
 

tobacco products
 

Income and increases in cigarette taxes 292
 

Indian Health Service (IHS)
 

cancer death rates
 

age-adjusted 155
 

lung cancer 143–146
 

cervical cancer 152
 

classification of smoking status 186
 

regional differences in cancer death 144
 

smokeless tobacco use 49–50
 

smoking cessation programs for pregnant
 

women 285
 

Infant outcomes, effects of smoking during
 

pregnancy 

birth weight 166–169 

morbidity and mortality 169–171 

Sudden Infant Death Syndrome 169–171 

International Multicultural Partnership 297
 

Interviewing methods. See Data collection and
 

analysis
 

It’s No Joke, Don’t Smoke! 274
 

It’s the Law voluntary compliance program 268
 

It’s Your Life—It’s Our Future 276
 

J 

Jackie Robinson Foundation Awards Dinner 219
 

Jargon, use in cigarette ads 242–243
 

K 

Kaiser Permanente 61, 161
 

Kool Achiever Awards 218
 

L 

Labor unions 208–209 

Lám Thê Náo Dê Bo Hút Thuô  ̧  ̧  ́ c? 276
 

Language/linguistics
 

proficiency, as barrier to knowledge of health
 

consequences 234
 

proficiency, as barrier to tobacco control
 

messages 262
 

proficiency as measure of acculturation
 

smoking prevalence 234
 

translation of smoking cessation
 

materials 274, 281
 

use of non-English words in tobacco product
 

materials 222
 

Law abidance 228, 232
 

Leadership Conference on Civil Rights 216
 

League of United Latin American Citizens 216
 

Legends Campaign 282–283
 

Legislation
 

sale of tobacco to minors (Synar
 

Amendment) 266
 

FDA tobacco product regulations 297
 

Liberalism, factor in smoking status 232
 

Life Skills Training (LST) Program 271
 

Lifestyle factors and decline in smoking
 

by ethnic group
 

African American youth 36–38
 

326 Index 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups

Low birth weight. See Infant outcomes, effects of 

smoking during pregnancy, birth weight 

Lung cancer 137–135 

African Americans 138–143 

American Indians and Alaska Natives 

143–145 

Asian Americans and Pacific Islanders 

145–147
 

Hispanics 147–149
 

M 

Magazines, ethnic
 

African Americans 218, 241–243
 

portrayal in tobacco ads 241
 

American Indians’ portrayal in tobacco
 

ads 223, 241
 

Hispanics 214
 

perception as trustworthy information
 

source 241, 274
 

See also Advertising tobacco products; Mass
 

media; Newspapers
 

Manual of the International Classification of Diseases, 

Injuries and Causes of Death (ICD) 187
 

Marijuana use in conjunction with smoking 37, 44
 

Mass media
 

radio 274
 

television 241, 274
 

See also Advertising, tobacco products;
 

Magazines, ethnic; Newspapers
 

Maternal smoking. See Pregnancy and smoking
 

Media literacy 241
 

Medicinal usage of tobacco. See Religious use of
 

tobacco
 

Memory. See Nicotine, physiological effects
 

Menthol cigarettes 79, 142, 224, 242, 243, 244
 

Metabolism of nicotine. See Nicotine pharmacology
 

Milwaukee County Youth Initiative 217
 

Minors’ access to tobacco. See Access of minors to
 

tobacco products
 

Misconceptions about causes of cancer 263
 

Monitoring the Future (MTF) surveys
 

description of 21, 96
 

perceptions of risks of cigarette
 

smoking 230–231
 

predictors of cigarette smoking in African
 

American youth 226
 

smoking cessation 97
 

smoking prevalence
 

American Indian and Alaska Native high 

school seniors 49
 

decline 36
 

young people 28, 30, 32, 37, 42, 44,
 

72–74 

MTV 274
 

Muscle relaxation. See Nicotine pharmacology
 

Musical events, ethnic targeting by tobacco
 

industry 218–219
 

Myocardial infarction 160, 164
 

N 

National Association for the Advancement of
 

Colored People (NAACP) 213, 216
 

National Association of African Americans for
 

Positive Imagery (NAAAPI) 224, 287, 296, 297
 

National Association of Black Social Workers 216
 

National Association of Negro Business and
 

Professional Women’s Clubs 216
 

National Black Caucus of State Legislators 215
 

National Black Leadership Initiative on Cancer
 

(NBLIC) 295
 

National Black Police Association 216
 

National Cancer Institute (NCI) 25, 74, 265,
 

277, 279
 

National Cancer Institute Advisory Panel on
 

Tobacco-Use Reduction Among High-Risk
 

Youth 269
 

National Center for Health Statistics (NCHS)
 

147, 154, 163
 

National Coalition of Hispanic Health and Human
 

Services Organizations (COSSMHO) 215, 218
 

National Directory of Asian Pacific American
 

Organizations 217
 

National Directory of Hispanic Organizations 217
 

National Coalition of 100 Black Women 216
 

National Conference of Black Lawyers 216
 

National Death Index 163
 

National Health and Nutrition Examination Surveys
 

(NHANES I, II, III) 71, 86, 161, 164, 181
 

National Health Interview Survey (NHIS)
 

adults 


beliefs about health effects of
 

smoking 264–265
 

cigarette brand preferences 79
 

cigarette smoking frequency 182
 

current cigarette smoking 87–90
 

effects of education and race/ethnicity
 

on smoking behavior 83
 

ethnic differences in quitting
 

smoking 183
 

exposure to environmental tobacco
 

smoke 86–87, 172
 

involvement of health care
 

providers 283–286
 

information needs 262–263
 

lung cancer death rates 146
 

Index 327
 
 

Surgeon General’s Report 

measures of tobacco use 97
 

pipe and cigar use 91–92
 

prevalence of smoking 35, 92–93,
 

98–121, 122–124
 

quitting behavior 261
 

smoking prevalence estimates 124
 

smoking status and ethnicity 84
 

use of smokeless tobacco 94
 

African Americans
 

and chronic obstructive pulmonary
 

disease 158
 

prevalence among successive birth
 

cohorts 74–75, 76, 140
 

prevalence of cigarette smoking 22,
 

23–24 

quitting behavior 25–26 

women of reproductive age 26–28 

young people 30–44 

American Indians and Alaska Natives
 

prevalence of cigarette smoking 44–45
 

quitting behavior 46, 48
 

women of reproductive age 48–49
 

young people 49–50
 

Asian Americans and Pacific Islanders
 

prevalence of cigarette smoking 56
 

quitting behavior 57
 

women of reproductive age 57, 59
 

young people 59–60
 

Hispanics 

prevalence among successive birth 

cohorts 77
 

prevalence of cigarette smoking 66–69
 

quitting behavior 70, 237
 

women of reproductive age 71–72
 

young people 72–74
 

National Heart, Lung, and Blood Institute 272
 

National High Blood Pressure Education
 

Program 286
 

National High School Senior Surveys.
 

See Monitoring the Future survey
 

National Hispanic Scholarship Fund 217
 

National Household Survey on Drug Abuse
 

(NHSDA) 28, 36, 72, 182
 

National Institute on Drug Abuse (NIDA) 28, 72
 

National Longitudinal Mortality Study 186
 

National Maternal and Infant Health Survey
 

(NMIHS) 27, 28, 49, 170
 

National Medical Association (NMA) 276, 282, 283
 

National Medical Expenditure Survey 44
 

National Minority AIDS Council 216
 

National Mortality Followback Survey (NMFS) 161
 

National Natality Survey 27
 

National Pregnancy and Health Survey 28, 72
 

National Research Council 172
 

National Survey of Family Growth 27, 71
 

National Survey of Oral Health in U.S. School
 

Children 174
 

National Urban League 215, 216
 

National Vital Statistics System 138
 

Native American Indians, by region and tribe
 

(smoking survey) 50–56 

Neighborhood tobacco product advertising 

221–222, 293–297 

Neural actions of nicotine. See Nicotine, 

physiological effects 

Neurotransmitter release, changes caused by 

nicotine See Nicotine, physiological effects 

New York City, proposed ban on public 

smoking 218
 

Newsletters, smoking prevention campaigns 274
 

Newspapers 214, 218. See also Magazines, ethnic
 

Nicotine dependence and addiction 181–184
 

Nicotine pharmacology 175–184
 

Nicotine, physiological effects 175–179. See also
 

Withdrawal symptoms, nicotine
 

Nicotine replacement therapy 286
 

Nicotine yield 179
 

Nonsmokers
 

exposure to environmental tobacco
 

smoke 137
 

support for bans on tobacco ads 293–298
 

O 

100 Black Men of America, Inc. 216
 

One Day at a Time 286
 

Operation PUSH (People United to Save
 

Humanity) 213, 216
 

Opportunities Industrialization Centers of
 

America 216
 

Oral cancer 153–155, 174
 

Oral lesions 174–175 

Oral leukoplakia 174
 

Outdoor advertisements. See Advertising, tobacco 

products 

Over-the-counter sales of cigarettes. See Access of 

minors to tobacco products 

Oxygen-carrying capacity, maternal, and effects
 

of smoking 171


 P 

Packaging 224
 

Parental attitudes toward smoking 40
 

Parental cigarette smoking, as risk factor for
 

initiation 229
 

328 Index 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups

Passive smoke exposure. See Environmental
 

tobacco smoke
 

Pathways to Freedom Community Demonstration
 

Project 280
 

Pathways to Freedom: Winning the Fight Against
 

Tobacco 276
 

Patterns of tobacco use. See Cigarette consumption
 

Peace pipe 210
 

Peer tobacco use 231–233
 

Perinatal mortality 166
 

Periodontal disease 174
 

Personal consultation for smoking cessation
 

face-to-face 278
 

telephone 278
 

Pew Charitable Trusts 217
 

Pharyngeal cancer 174
 

Philadelphia Mayor’s Commission on Literacy 217
 

Physicians
 

advice to patients regarding smoking 283–285
 

appearance in tobacco advertisements 243
 

Physiological measurement of cigarette smoking.
 

See Biochemical markers of tobacco use
 

Pipe smoking
 

definition for surveys 92
 

history of 91–92
 

prevalence of 91–92
 

Point-of-sale displays. See Advertising, tobacco 

products 

Political campaign contributions by tobacco 

companies 217
 

Portland Life Center 216
 

Power distance 283
 

Predictors of tobacco use and initiation 231–233
 

Pregnancy and smoking
 

abruptio placentae 171
 

African American vs. white 167–169
 

and other drug use 168
 

birth weight 166, 167–169, 171, 185
 

ectopic pregnancy 171
 

intention to breast-feed as predictor of smoking
 

cessation 260
 

intrauterine growth retardation 166
 

preterm delivery 169
 

reduction of cigarette consumption 27, 71,
 

167, 169
 

Sudden Infant Death Syndrome (SIDS) 

167, 169–171 

See also Infant outcomes, effects of smoking 

during pregnancy; Smoking prevalence, 

during pregnancy 

Prevalence of cessation 8
 

Prevalence of smoking. See Smoking prevalence
 

Preventing Tobacco Use Among Young People: A Report
 

of the Surgeon General 44, 220
 

Prevention programs. See Mass media; School-based 

health education approaches 

Product endorsements. See Advertising, tobacco 

products 

Product targeting 

American Spirit cigarettes, American 

Indians 223
 

Dorado cigarettes, Hispanics 220, 222
 

Mild Seven cigarettes, Asian Americans 223
 

Rio cigarettes, Hispanics 220, 222
 

Uptown cigarettes, African Americans 222,
 

223–224, 294
 

Project SHOUT 271–272
 

Project SMART 271
 

Programa Latino Para Dejar de Fumar 279–280
 

“Proposition 99” tobacco tax initiative 217, 277
 

Psychosocial risk factors 225–233
 

Public health objectives 5. See also Healthy People
 

2000
 

Public places, antismoking policies. See Smoking
 

bans in public places
 

Public service announcements 279
 

Q 

Quit attempts. See Smoking cessation programs, 

quit attempts
 

Quit for Life, employer-provided program 282
 

Quit Today! 280
 

R 

Race. See Ethnic groups
 

Racial discrimination 214, 260
 

Radio. See Mass media
 

Rappers/Pick It antismoking message 221
 

Rates of smoking. See Cigarette consumption
 

Recidivism. See Relapse
 

Regular smoking, definition of 97
 

Reinforcing effects of smoking tobacco 176
 

Relapse 25, 122, 261–262
 

Religion as protective factor 42, 226, 232
 

Religious use of tobacco 210
 

Reporting bias. See Data collection and analysis
 

Reproductive health. See Pregnancy and smoking;
 

Smoking prevalence, during pregnancy 

Resource guides for ethnic groups, tobacco industry 

support of 216–217 

Retrospective analysis methodology. See Data 

collection and analysis 

Revenues. See Advertising, tobacco products, 

revenues 

Index 329
 
 

Surgeon General’s Report 

Risk-taking behavior, factor in tobacco use 44, 73,
 

95 

Robert Wood Johnson Foundation (RWJF). See Youth 

Access Survey 

Role models. See Advertising, tobacco products 

Rompa Con El Vicio. Una Guía Para Dejar de 

Fumar 275
 

S 

Salem FreshsideTM Salute 218
 

Salem Open tennis tournament 211
 

Sales to minors. See Access of minors to tobacco
 

products
 

San Antonio Heart Study 164
 

School-based health education approaches 269–273
 

School performance. See Academic performance
 

and smoking initiation
 

Schools, antismoking policies 289
 

Second-hand smoke. See Environmental tobacco
 

smoke
 

Self-help approach to smoking cessation 275–277
 

willpower 275
 

Self-reports of nicotine addiction, by ethnicity
 

181–183 

Self-service tobacco displays, 

elimination of 266, 269
 

Sex differences. See Gender differences
 

Sharing cigarettes 211, 212
 

Sí Puedo 280
 

Sickle cell trait and smoking, effects on birth
 

weight 171
 

Sidestream smoke. See Environmental tobacco
 

Smoke
 

Smokefree policies. See Smoking bans in public
 

places
 

Smokeless tobacco addiction 183
 

Smokeless tobacco use
 

by ethnic group
 

African Americans 44, 94, 174
 

American Indians and Alaska
 

Natives 49–50, 55, 94, 174
 

Asian Americans and Pacific
 

Islanders 60, 94, 174
 

Hispanics 74, 94
 

cessation programs 234
 

effects of 174–175
 

factors associated with initiation 232–233
 

prevalence 233–235
 

Skoal Bandit promotion 218, 219
 

use by adolescents 174, 232–233
 

Smokers, acceptance of. See Attitudes toward 

tobacco use; Cultural values; Social influences 

Smokers, definitions 97
 

Smoking abstinence, overnight, and loss of nicotine
 

tolerance 178
 

Smoking: Facts and Quitting Tips for Black
 

Americans 277
 

Smoking: Facts and Quitting Tips for Hispanics 277
 

Smoking bans in public places 287–292
 

enforcement in ethnic communities 289
 

Smoking cessation programs
 

age at cessation 46
 

among members of ethnic groups 14,
 

274–283, 286–287
 

approaches 259
 

attrition rate 277
 

culturally appropriate 259–262, 273, 274–283,
 

286, 287
 

desire to quit 260–262
 

education and ethnicity as factors 85
 

employer-provided programs 286
 

family-centered interventions 260
 

Freedom from Smoking in 20 Days 281
 

health benefits of 263–265
 

home visits 278
 

information needs 262–263
 

motivation to quit 260
 

nontraditional providers and 286–287
 

perceived ability to quit 286
 

pregnant women 285
 

prevalence of former smokers
 

African Americans 25
 

American Indians and Alaska
 

Natives 46
 

Asian Americans and Pacific
 

Islanders 57
 

Hispanics 70
 

quit attempts, African Americans 25–26, 236
 

See also Community; Group approaches to
 

smoking cessation; Self-help approach to 

smoking cessation 

Smoking initiation
 

adolescents 225
 

by ethnic group
 

African Americans 40, 78, 226
 

American Indians and Alaska
 

Natives 227
 

Asian Americans and Pacific
 

Islanders 227
 

Hispanics 40, 78–79, 228–229
 

long-term trends, birth cohort analysis 78–79
 

multiple group studies 229
 

targeted advertising 223, 240–244
 

Smoking prevalence
 

among adults 21–23, 26–28
 

among ethnic groups 12
 

330 Index 
 

Tobacco Use Among U.S. Racial/Ethnic Minority Groups

among young people
 

African Americans 28–31, 44
 

American Indians and Alaska
 

Natives 49
 

Asian Americans and Pacific
 

Islanders 59–60
 

Hispanics 72–73 

See also Monitoring the Future surveys 

by ethnic group 

African Americans 22–25, 35, 74–75, 233
 

American Indians and Alaska
 

Natives 44–46, 50–56, 233
 

Asian Americans and Pacific
 

Islanders 56–59, 234
 

Hispanics 66–70, 75–77, 234–235 

comparisons among ethnic groups 87–91 

decline in smoking 

African Americans 27, 30, 31, 36, 38, 41,
 

74–75, 78
 

American Indians and Alaska
 

Natives 49
 

Asian Americans and Pacific
 

Islanders 56–57, 59, 61
 

Hispanics 69, 71, 75–76, 78–79
 

decreased by cigarette taxes 292–293
 

during pregnancy
 

African Americans 26–28, 29, 285
 

American Indians and Alaska
 

Natives 29, 49, 285
 

Asian Americans and Pacific
 

Islanders 29, 59, 285
 

Hispanics 29, 71–72, 285
 

education and ethnicity as factors in
 

smoking status 83–86
 

in Asian countries 65–66
 

in Latin American countries 69
 

in women of reproductive age
 

African Americans 26–28
 

American Indians and Alaska
 

Natives 48–49
 

Asian Americans and Pacific
 

Islanders 57, 59
 

Hispanics 71–72 

regional and tribal tobacco use 50–56 

retrospective analysis and assessment of 

African Americans 74–75 

Hispanics 75–76 See also Gender 

differences 

Smoking prevention programs. See Mass media; 

School-based health education approaches 

Smoking recidivism. See Relapse 

Smoking reduction during pregnancy. 

See Pregnancy and smoking 

Snuff use. See Smokeless tobacco use 

Social influences
 

smoking prevalence in Latin America 212
 

status-seeking behavior 224, 240–241
 

tobacco use at American Indian social
 

gatherings 210
 

See also Cultural values
 

Social Learning Theory 282
 

Social skills/peer pressure
 

resistance training for youth 271
 

Sociodemographic factors and decline in smoking
 

by African American youth 36
 

Socioeconomic status
 

coronary heart disease deaths 161
 

exposure to school-based smoking prevention
 

programs 269
 

factor in the response to changes in cigarette
 

price 292
 

smoking prevalence 83
 

targeting of ads 240–244
 

Software, interactive learning programs 273
 

Sponsorship by tobacco industry. See Tobacco
 

industry
 

Stages of change 225
 

Stanford Five-City Multifactor Risk Reduction
 

Project 279, 284
 

Stomach cancer 155
 

Stop Teenage Addiction to Tobacco (STAT) 268
 

Stress. See Coping mechanism, cigarette smoking
 

Strong Heart Study 45
 

Stroke as the major form of cerebrovascular
 

disease 164
 

Suc Khoe La Vang! 283
 

sudden infant death syndrome (SIDS) 169–171
 

Surveillance, Epidemiology, and End Results (SEER)
 

Program 138, 146, 149, 151, 152, 156, 186
 

Surveys. See specific survey: 

Adult Use of Tobacco Survey (ALTS) 

Behavioral Risk Factor Surveillance System 

(BRFSS) 

Current Population Survey (CPS) 

Hispanic Health and Nutrition Examination 

Survey (HHANES) 

Monitoring the Future (MTF) surveys 

National Health and Nutrition Examination 

Surveys (NHANES) 

National Health Interview Survey (NHIS) 

Surveillance, Epidemiology, and End Results 

(SEER) Program 

Teenage Attitudes and Practices Survey (TAPS) 

Youth Access Survey, Robert Wood Johnson 

Foundation (RWJF) 

Youth Risk Behavior Survey (YRBS) 

Synar Amendment. See Legislation 

Index 331
 
 

Surgeon General’s Report 

T 

Task performance. See Nicotine, physiological 

effects 

Taxes on tobacco products 

excise taxes 292–293 

sales taxes 292–293 

Teach For America 217
 

Teenage Attitudes and Practices Survey (TAPS) 21,
 

32, 36, 73, 81, 83, 96, 228, 266, 267
 

Terms related to tobacco use 8
 

Television. See Mass media
 

Tobacco, alternative uses. See Religious use of
 

tobacco 

Tobacco companies
 

American Tobacco Co. 242, 244
 

British American Tobacco Co. 212
 

China National Tobacco Corporation 211
 

Brown & Williamson Tobacco Corp. 217, 224,
 

242
 

Japan Tobacco Inc. 223
 

Liggett & Myers 242, 243
 

Lorillard 223, 241, 242, 243
 

Parliament 219
 

Philip Morris 216, 217, 218, 222, 241, 242
 

RJR Nabisco (R. J. Reynolds) 215, 216, 217,
 

219, 223, 224, 244
 

Sante Fe Tobacco Co. 223
 

Tobacco Institute 216
 

United States Tobacco Co. 219
 

Tobacco control. See Smoking cessation programs 

Tobacco industry 

African American involvement 208–209, 

213–214
 

Asian production 211
 

community loyalty 213
 

funding of community agencies and
 

organizations 215–217
 

Latin American production 212
 

shift of expenditures to promotional
 

marketing 293
 

support for arts 218–219
 

support for cultural activities 218–219
 

support for education 217
 

support for ethnic communities, pride, and
 

culture 213, 216
 

Tobacco Use. See Smokeless tobacco use; Smoking
 

prevalence
 

Tobacco-Use Reduction Among High-Risk Youth,
 

NCI Advisory Panel 269
 

Tobacco Workers International Union 208
 

Tumor suppressor gene p53 143
 

U
 

Union of Pan Asian Communities 287
 

United Cambodian Community, Inc. 287
 

United Negro College Fund (UNCF) 215, 216, 217,
 

219
 

United Tobacco Workers 209
 

Urinary bladder cancer 156–157 

V
 

Values, used as a means of smoking cessation and
 

health promotion effort 260
 

Vending machines 268–269 

Victory Over Smoking—A Guide to Smoking
 

Cessation for You and Your Family 277
 

Vietnamese Community Health Promotion
 

Project 283
 

Virginia Slims fashion show 211
 

W 

Warning labels 298
 

Warning signs mandated by state, prohibition of
 

sales to minors 268
 

Weight control and cigarette smoking 38–39, 277
 

Withdrawal symptoms, nicotine 178–179
 

Women. See Gender differences; Smoking
 

prevalence 

Workplace environmental tobacco smoke 

exposure 287–288 

See also Environmental tobacco smoke 

Y 

Young Men’s Christian Association 216
 

Youth
 

advertising, effectiveness of 41
 

alcohol use 37, 38
 

attitudes toward tobacco use 38–41
 

knowledge of health consequences
 

of smoking 227
 

skills training 271
 

See also Adolescents; Mass media; School-based
 

health education approaches; Smoking
 

initiation; Smoking prevalence
 

Youth Access Survey, Robert Wood Johnson
 

Foundation (RWJF) 269, 293, 298
 

Youth access to tobacco. See Access of minors to
 

tobacco products
 

Youth Risk Behavior Survey (YRBS) 29, 36, 44, 73,
 

74, 96
 

332 Index